Chest Wall Deformities with Dr. Robert Kelly

Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current is created and edited by Todd Ponsky, Nicholas Bruns, and Ian Glenn in partnership with Globalcast MD and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome to State Current and Pediatric Surgery. I'm Todd Ponsky from Akron Children's Hospital, and today we are joined by Dr. Robert Kelly, who is the surgeon in Chief and vice president for surgical affairs at the Children's Hospital of the King's Daughters and professor of clinical Surgery and Pediatrics, Chief Division of Pediatric Surgery at Eastern Virginia Medical School. Dr. Kelly, thank you for joining us today. Well, thank you for the chance to be here, Todd. Well, I know that you do all sorts of pediatric surgery, but of course what you're obviously most well known for is the treatment of pectus disease, pectus carinatum and pectus excavatum, and obviously this is a wide area of interest all around the world, so a lot of people have been asking us to do this particular podcast, and I really appreciate you joining us today. Oh, it's a pleasure, Dr. B. So Rob, let's get started with the most basic question. is how does one decide who exactly needs surgery for pectus excavatum? 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. These symptoms are generally not things that occur at rest, but rather with with exertion. Uh, and then if one examines the patient and Has the subjective impression that there is a significant depression in the chest. We try to, uh, at our center look at an objective panel of tests to try to figure out what effect the problem has on the patient's anatomy, on their lung function, on their heart function, uh, to some extent on their, on their body image. I, I have a patient on my clinic schedule. They're coming in for, it says evaluation for pectus excavatum. What kind of things just to make sure I, I want to make sure I have this all right. What am I going to need to look for and ask and do on that first clinical visit? Number one is get a good history about what kind of symptoms they may be having. Um, is there anything else that I need to pay attention to? Before going ahead and ordering those tests, well, on exam, it certainly would be worthwhile to see whether you think the patient has a syndromic problems. So both Marfan syndrome and Ehers-Danlos syndrome are problems for which pectus excavatum is a marker. And if you're concerned about those, you would, would want to do the same things we discussed, but with particular attention to making sure you haven't found, missed other problems with Marfan's, eye problems as an example. Um, and, uh, uh, we also, uh, check patients for metal allergy and so we try to find if there's a family history of metal allergy or if the patient has a history of metal allergy, um, him or herself. OK, talk to me about how now I'm ready to examine their chest. Uh, how do you, what do you look for? How do you best examine the chest to get a better understanding of what you're going to be doing? 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 so that 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. And 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. And pointing that out to patients and families when it's present, helps them to understand why there would be the symptoms of shortness of breath with exertion that. They would have because the bellows action of the chest is impaired. Um, patients frequently compensate with abdominal breathing, so watching the abdomen during that process can help to see why the patient really doesn't have trouble breathing when they're at rest. Um, uh, but breathing is less efficient when the bellows doesn't work properly. So after a time, after they've run for a while, then they've had to work harder, and that's maybe why they tire out before the next person. OK. And what, what other things might you look for? I know you, I'm assuming you look at sort of the symmetry of the chest. And the flaring and all those things as well. Yes, looking for displacement of the cardiac impulse is useful, and many patients have stria on the on the back, stretch marks on the lower back, and we don't really know why that is, but it's certainly associated with connective tissue troubles, and they're something to note and. Uh, be, be aware of and when you see that to consider even more whether there's a connective tissue disorder. We also were looking at the patient from the back, try to see if the patient has scoliosis because, uh, 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. So an important thing to keep track of and to see whether that merits evaluation on its own. So let's say it does. Let's say they have bad scoliosis. What, what should be done first? Well, what we've favored doing is to try to see which is the more clinically disruptive problem so that if the patient has a really severe scoliosis, so that they're past a 40 or 50 degree bend and the orthopedic surgeon is believing that they need some kind of Procedure to straighten their spine, but their pectus is, is not so troublesome, then we would favor going ahead with the spine first. If on the other hand, they have the sort of problem where the sternum is, is touching their spine and they have a mild scoliosis, then obviously go in the other direction, and you need to carry this out in consultation with the orthopedic surgeon if it's bad in both directions. So let me, let me just understand this because as I, I want to make sure I get who gets all this work up. So if a patient comes in, you mentioned the symptoms that they have to have, you said, uh, fatigue and shortness of breath, uh, upon exertion. Is that right? Did I get those correct? You're right, and pain in the chest wall and chest pain in the chest wall. So if they come to you and they have a pretty impressive moderate to severe pectus excavatum, but when you ask them, they say, you know, I really don't have much shortness of breath or fatigue. Are they, are they then not a candidate for repair? Well, If the patient maintains that they have absolutely no symptoms, uh, it, it may be worthwhile to press them a little bit and find out how much physical exercise they're actually doing. If there are any number of people that actually have learned to avoid physical exercise, uh, in part because of that. So if one thinks the patient has a bad anatomic problem, it's surely a reasonable thing to go ahead and do the investigations, as you may well uncover things in heart or lung function that weren't evident by the patient's history. I say not, not everyone has the symptoms. When we did the multi-center study at PE excavatum, 11 centers, we found roughly 2/3 of the patients had. Had those kinds of symptoms. OK, so you've evaluated the patient and they're in your office. Then you said, I think you said you order a CAT scan, pulmonary function tests, and an echo. Is that correct? That's right, yes. So we have found most useful the CT scan in trying to assess the anatomy of the chest, and that will show not only the depth of the depression, but also the The effect that the chest wall has on the heart and the lungs and it will show the cephalocaudal extent of the depression, helping to plan whether one bar or two bars would be useful in patients who would appear to need an operation. That uh CT scan can help to determine when using a technique to elevate the sternnament operation where that could be well attached, so. The CT scan has been useful for us. What do you look at on the scan to help you plan your operation? Haller index, the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine, uh, is, is the most widely utilized ratio to try to decide who has a severe pectus, and that was. Uh, reported by Heller in 1987, and he suggested that if the index was greater than 3.25 that you had a severe pectus. Subsequently, uh, the group in Kansas City has recognized that in a patient with a barrel chest, the depth of the depression is underestimated because the AP diameter is, is increased. So they have advocated looking at uh. Uh, an index which shows the distance between the back of the sternum and the front of the, the spine, at the depression divided into that same distance. More laterally where the chest is at its normal location and where the chest will come to, and they've advocated if that if that is more than a 10% uh uh drop due to the the uh pectus that one consider that as a as a reason to operate. That that index, however, hasn't found, uh, uh, wide recognition outside people with interest in Pus and so and so, uh, uh, while that's something to, to look at, it's, it's not something that your pediatrician or pulmonologist may be familiar with. Certainly the MRI can be used as well, but we have found it difficult to, to see as well where the cartilaginous and bony structures are by MRI. And so in general we favor a low dose CT scan which we have available here. That's, I have a few questions for you, Rob. So I'm, I'm glad you mentioned the MRI. Just a few weeks ago we did a global cast uh in Cincinnati, and I know they're very heavy in the use of MRI and moving towards that modality, um, but it sounds like you still prefer the CT scan. Well, with the, the, uh, the MRI scan, if, if you are able to quantify both the effects on the heart and the anatomy at the same time, then that could be a very valuable thing. We did actually begin an effort with Cincinnati, I think, 4 years ago or so now to try to look into this, and we shared some patients on evaluating cardiac MRI. But it turned out to not be a very practical sort of thing, at least, uh, uh, in that the investigations took a long time. They, they took hours, uh, and, uh, the Images again of the cartilaginous and bony structures were not as easy for someone who isn't a radiologist to identify. So we, we have felt the CT scan is, is, uh, easier for us to use and it's certainly logistically easier for the patient and family can be done in a much shorter period. of time. What exactly, I mean, I guess you're looking for heart strain. What are you looking for on the echo? The echocardiogram, the most frequent thing that's noted is mitral valve prolapse, which is present in about somewhere in the order of 14% of patients in our series. In young patients, mitral valve prolapse should be present in about 1%, so it clearly is present in increased amount. On echo, one can sometimes see the right ventricular compression, though that may commonly not be seen on the echo even if it's evident on a CT scan. OK, so you've ordered your echo. They they then get pulmonary function tests and Um, I'm, I'm assuming in a lot of these patients you'll see, uh, deficiencies within their pulmonary function tests. Yes, on, on, on average, in a large number of patients, the pulmonary function tests will be down by about 1 standard deviation from average. So that, uh, recalling that on pulmonary function tests, 100% is average for the particular value, let's say FEV1. Uh, and the people who, uh, set this up, set it up more or less like an IQ test, so that 80% predicted is two standard deviations below the average and then 120% predicted is two standard deviations above. So if we have patients that are about a standard deviation below, they're somewhere between 85 and 90% predicted, which doesn't make a lot of impression on anybody except for that in in our series and that in the multi-center study, patients came up by close to a standard deviation when they had the bellows action of the chest restored. We have a significant fraction of patients who have. Restrictive lung disease, which you recall is defined as an FVC less than 80% predicted with a normal FEV1 FEC ratio. So if you have asthma, of course you're going to have a low FEC, but it's because your small airways are bad, and that is not corrected by a Pus operation. Uh, but, uh, restrictive process certainly is, uh, and, and so that's something else to look for. We've seen that patients have a worse pectus that they have more likelihood of having restrictive problems. Our indications for operation really are we look at six things and try to see that patients should have at least 3 of them. So we look for a Haller index greater than 3.2. We look for pulmonary function tests that are decreased below 80% predicted. We look for on the echo, cardiac compression, mitral valve prolapse, or other abnormalities noted by the cardiologist. We look for symptoms and what I haven't mentioned thus far is if it's, if it is a progressive pectus, so that we know that around the time of the teenage growth spurt, there are a lot of kids in whom the pectus gets a lot deeper. And if that's something. Which is clear that it is getting worse, then we certainly view that as a reason to make an intervention so that it doesn't get even more difficult to correct. And then patients who have major psychosocial issues related to their body image from the pectus, I think we consider that as a as a reason as well. OK. Um, and so you, you get the CAT scan, you get the echo, you have the pulmonary function tests, and they have more than 3 of those criteria. So, uh, you go ahead and you schedule them for surgery. Um, talk to me about a few things. First, I'm curious about, um, what's the ideal age, and then also just get into what do you tell the parents? How do you prepare them for surgery, uh, both by what you advise them and also any other things you need to do for preoperative preparation, so. I asked a lot there. So first, let's get to what's the ideal age. We believe that the ideal age is sometime just prior to the onset of puberty or early in puberty. So in girls, say 11 to 13, and in boys a year or two older than that. That age has the advantage that The bar is in place during the time when the pectus is most likely to get deeper during that rapid growth spurt, and we've found the likelihood of recurrence in someone who has gone through the growth spurt of puberty is, is extremely low, uh, so that if the bar can be in place until that process is, is completed or nearly completed, uh, that seems like a good age. That being said, there, there are some Asian groups that operate on people when they're, when they're quite young, uh, well under 10 years old, and they report they have had good results there as well. OK. Um So and that's out of Korea, is that right? Yes, that's OK, Park, Dr. Park, yeah, so, um, now the second question. So what do you tell the families about what to expect from this operation? 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. I think reassuring patients and families that we can treat pain is really important, and if you point out to the adolescent that uh when you have general anesthesia, you can have really painful things done to you and you don't even know about it, uh, they can be reassured that yes, they can. Take away my pain, whatever it is I have, and we'll mention to them that 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. That, that's really worth a lot after operation if they knew something was going to happen and that they knew they could do something about it, we use a patient controlled analgesia PCA pump, uh, with a steady background dose of narcotic and then an ability to push a button and give a booster dose. And if we emphasize to the patients that, uh, the night of surgery, we need to dial that in. So 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, uh, increasing the dose, uh, switching medicines, adding another medicine, adding another combination, a lot of things can be done. That's very reassuring to patients and their families. Do all of your patients get an epidural? None of our patients get epidurals at this point. No, we haven't used them for several years, OK, uh. Which I think other things in terms of preoperative preparation, we emphasize the need for patients to do spirometry hourly when awake, uh, to be walking beginning the day after operation, we emphasize that it's important how frequently the patient gets up rather than how far he walks. Um, we emphasize efforts at nutrition that the patient should try to eat something, a couple 100 calories every couple hours if they don't have their usual appetite, which. About half the patients don't have their usual appetite. About half of it isn't bother them at all. They eat very well, uh, and then we also encourage patients to not rush the process of recovery, to give themselves time to realize this isn't a contest to get out of the hospital before, uh, uh, it was predicted you would get out, uh, and, and those things generally, uh. Uh, put patients in a, in a good sense that they have an idea of what's coming and that they can do something to help make it better. So those are the kinds of things to tell. We do tell patients in terms of return to activity after operation that for the first month they really shouldn't do anything but walk and activities of daily life, um, and beginning at 1 month they can liberalize physical activities and by 3 to 6 months they can be doing pretty much any activity. Except we don't advise them to do things, we advise them not to do things where they know they'll get a blow to the chest. So 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. So those are the kinds of preoperative discussion things we do. That's great. What about preoperative testing or do you get blood? Do you get typed and cross or what do you do to prepare, prepare for surgery? Well, one important thing is we do try to check the patient for metal allergy. Um, we use the allergies test which is developed in Canada, and the advantage of that test, uh, over, uh, other tests, uh, such as using a disk and taping it to the patient, uh, or, or, uh, uh. Using other types of tests is that it includes all the components of the stainless steel bar, and we've had people react against a number of the minor components. So if the patients do react against, most commonly nickel, but also chromium and cobalt and various other things that are in the bar, they can have a titanium bar, but the titanium. The bar has to be bent at the factory, and because of that you have to order it in advance. The titanium is also, at least presently, much more expensive than the stainless steel. So in a in an era when we should be trying to do responsible cost containment for medical costs, if one thing works quite well and costs a lot less than the other thing, we should use the less expensive bar. Um, but, uh, the, the metal allergy testing would be the main thing in terms of preparation. We do type and screen the patients, um, uh, but the likelihood of transfusion is exceedingly low. Mhm. Got it. Talk to me about, uh, and I know this is hard to do in such a short period of time, but can you go through the main pearls of the operation? Well, there, there are several technical details that, that are, uh, uh, really important, um. Uh, positioning the patient, uh, is important, um, and I think that anyone listening should, should really, uh, look and, and, uh, look at diagrams of how to position. There are different ways that are, are satisfactory, but you don't want to have the patient have a brachial plexus problem afterwards. Measuring so the bar is the correct length and measuring from mid-axillary line to mid-axillary line and subtracting an inch is one way that works very well, um. The skin prep is, is very important. We use, uh, uh, a, uh, Hibicleanse shower the night before, the morning of. We wipe the patient down, and then we use ChloraPrep so that the skin's pretty clean as much as we can do. We give perioperative, uh, antibiotics, generally, uh, ANEF or something suitable in the case of an allergy. Uh, we mark the patient, mark the intercostal spaces, mark the deepest part of the pectus, uh, mark where the rib margins are. Um, and then I think one of the most important things is to use thoracoscopy so that when, uh, uh, you're passing the instrument between the back of the sternum and the pericardium, you can see, uh, so we're strong advocates of thoracoscopy recognizing there are people who do the operation without it. And, and Rob, I want to interrupt you because I want to state the obvious, but that, that we're talking about the NU procedure and not the ravage at this point. Yes, I'm so sorry. Yes, this is for the NUS procedure, right? OK. Uh, for the NUS procedure, we think, 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. So there are a number of ways to elevate the sternum. One is to use the vacuum bell, a suction cup that's put over the depression, and suction applied will lift up the chest. Uh, one can make an incision inferior to the xyphoid. And put a finger behind the sternum and lift it to the ceiling or put a bone hook behind the sternum and lift it to the ceiling. What we favor at this point is using the rule track device, which is something the cardiac surgeons use for holding up the left side of a split sternum to take down the internal mammary and, uh, and using that to. A lift up on a blunt-ended curved instrument which one puts in through a 3 or 4 millimeter stab wound just adjacent to the lower sternum, and then lift it up like a crane to lift the chest wall right out of the way, and that really is a very nice way of making it so you can see very well and the path from one side to the other is very easy to identify with with that crane in place. Um OK, external elevation really important, um, when, when passing the introducer from one side to the other, 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. Uh, so if you do that, the likelihood of injuring the heart is, is exceedingly low, uh, um. After the tunnel is created and the bar is passed back across and positioned, then a really important thing is to prevent the bar from moving out of position. We favor using a tongue in groove type stabilizer on one end of the bar. But one could also, uh, do without that and wrap around the bar and the adjacent rib, uh, with, uh, we use heavy absorbable suture, number 1 PDS, and we'll commonly put, uh, 4 thicknesses of that around the intersection of the bar and the rib. Um, others, uh, have used, uh, fiber wire, but we like using something that's absorbable. Um, and, uh, uh, those are really key things to having a good result and then of course a layered closure at the end. Tell me where you make your incision relative to where I'm assuming it's relative to where the deepest point is. Yes, more or less at, at the level of, uh, the cephalo caudad level of the. Deepest point of the pectus, uh, more or less from the anterior to the mid axillary line, a 2-3 centimeter incision usually works very well, uh, in, in, uh, girls who have developed breasts, uh, that is their, uh, post pubertal, making an incision where the breast meets to the chest wall, um, in, in a, uh, uh, curved incision extending, uh. from the head down towards the feet along the line of the breast gives excellent access. It's a little more medial than the other incision, which can be more convenient. And when practical, we try to go posterior to the pectoralis major. OK, and, and the uh the bar, tell me where you want the bar to be resting at the sort of the the peaks of the of the ribs. Is that right? Yes, as you're saying, the mechanics of the situation is that the sternum will be pushing towards the floor and the patient lying on the operating table, and there needs to be something that provides a counterforce to push the. Uh, bar the other direction and 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. So you want to go into the chest medial to the pectus ridge, and that way there is a rib which is providing a counterforce. There are two ribs, one to the right and one to the left to the center of the depression, which are, which are providing a force anteriorly while the sternum pushes posteriorly. Got it. So you make your incision on the lateral but actually tunnel up and over the rib a little more medial. Yes, and sternal elevation dramatically helps that process so that when the chest is more or less flattened out, it's, it's much easier to do that than when the chest is not, OK. And you only put the scope in on the one side, correct? Well, we, we advocate doing whatever you need to do to see. Got it. If you need one on the left, why not? Got it. OK. And one versus 2 stabilizers. 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. The patient has two bars, one on the left, one on the right. Got it. And I'm assuming the decision to have two bars really comes with experience and, and um. Really something that I don't know if that's something you could address quickly or if that's more of a complicated, complicated question. If the patient is very tall, if the patient is over, let's say something like 6 ft 2 inches tall, the chances you're going to need two bars are almost 100%. So you can start there. But if the patient isn't, then you really do have to look and see how the sternum came up at operation. Great. OK. Oh, so sometimes you'll put one in and say, you know, I think we need another one. Yes, got it. And I, I want to actually use this as an opportunity. We're obviously glossing over something that's very complex, and I know, um, you've regularly been giving the courses there at King's Daughters. Are you still giving those courses? Yes, and this year we'll, we'll have what should be a much bigger meeting. The Chesswall International Group will be meeting June 15th through 17th here in Norfolk, Virginia, and we'll have people from all around the world giving perspectives on various aspects of this. How can people find out more about that if they want to come? They Google. HKD Children's Hospital of King's Daughters or CWG CWIG Chestwall International Group 2016, that that should take them to the site. Perfect. That's great. That's great. When they're in the hospital postoperatively, um, do you have a pretty standard protocol on how long they stay and, and what happens each day? Um, not really, we, we, well, we do, we certainly allow for, uh, uh, individual patient variation, but we try to wean the patient off the PCA pump, uh, stopping the basal rate generally on the second day and stopping the PCA. altogether on the 3rd day. So by the 3rd day, the patient's on all oral medicines, uh, and we certainly work on mobilization beginning day 1, walking stairs day 2, and, and so on. OK. All right. Is anything else with the technique techniques, any um. Any pitfalls you want to talk about that could be avoided? You know, I, I think those, those things are important. Bending the bar so that you don't have too much overcorrection is important, but at some stage one gets into a lot of detail, OK. So, so what about complications? I know that it can be, get a little bit of tachycardia as you're passing over the heart. What are some of the complications and what can be done to avoid those? Well, fortunately, in multiple series, the short term complications are, are few and intervention has been infrequent. Longer term bar displacement has been the big difficulty, and in our series about 2.7% of patients, and we're up somewhere now past 2000 NUS procedure. He have required some sort of revision. That incidence has been cut to about half that number by using stabilizers and wrapping around the crossing of the bar to the rib with the with the pericostal sutures. That really has been the thing that has helped it. Bar displacement is still going to happen because. Uh, most of what happens for bar displacement in our experience now, there's some kind of a marked force. So for example, I had a fellow who wanted to know if he could go back to riding a bicycle, and we said, sure, you know, of course you want people to do cardiovascular activity, but he, he was a mountain biker and he went down a mountain bike trail, went off the trail and hit a tree, and it knocked his bar in a position. Well, I mean, you know, you can't prevent everything in this life, so, uh, some of those things will, will still occur. The uh bar allergy, we, we have had, uh, a little less than 1%, 0.9%. We've been screening for that since 2004, and that has, uh, dramatically decreased the, the, uh, incidence of the of the bar allergy. Um, we had about 6.4% of our patients had, uh, clinical or patch test evidence of metal allergy, um, and, uh, so that's something to, to look at to see what you can avoid. Wound infection we've had, uh, in 2.3% of patients, more than 2/3 of those have been superficial or cellulitis, um. We really make a big thing of skin preparation and giving perioperative antibiotics. We have a bundle of activities commonly like other common infection bundles that we do, which Doctor Bob Obermayer should have come out in the Journal of Pediatric Surgery in short order. Um, recurrence in about 1.2% of patients, and prevention of recurrence is something which is still poorly understood. Why anybody has a recurrence is, is really not so, not so clear. Certainly if the bar is taken out early and In in our series we have Doctor Nuss's early experience where he took the bar out after only a few months because, uh, gee, if you have a fracture, you leave a cast on only for 6 or 8 weeks in many cases, uh. But uh it still isn't clear sometimes why, you know, one will go to a meeting and someone will say, gee, I left the barn for 3 years and took it out and I still got a recurrence and uh so I think there's more work to be done to understand why a recurrence happens, um, but focusing on the technical measures will, will surely help to decrease the likelihood of of complications. And again I the other for the uh those who are listening to the podcast, um. If you access the stay current app, um, we will have videos, uh, highlighting some of the techniques that Doctor Kelly's been addressing here. So and then I know you've already talked to us a lot about some of your postoperative protocol, uh, with getting them up and, and any other pearls for your postoperative protocol? I'm, I'm assuming you have a and actually I know that you have a very well drawn out protocol for these patients. I think the main thing would be to be sure that one sees the patients at some interval afterwards. We try to make a big thing of seeing the patients at 6 months after operation and then trying to organize when the bar removal is going to be. We favor removing the bar closer to 3 years than to 2 years, but. It certainly needs to be at least 2 years before the bar comes out, um, and you're talking about long intervals of time to not see someone with an implant, so we, we do favor trying to keep an eye on the patients by seeing them on a more or less annual basis to be sure things are, uh, everything remains good. Before we move on to Kanaum, um, was there any other points that you wanted to make about excavatum? There, there's one really important thing which is that, uh, there's, there's now available a non-operative treatment for patients who, especially who have a minor degree of pecu excavatum, and that's the vacuum bell, uh, treatment which, uh, was developed by a fellow named uh Cloe in, in Germany and just a, uh, uh, very recently a paper from uh Journal of Pediatric Surgery about the efficacy of this from, uh, hospital in Saint Etienne, France, uh, and they found it to be, uh. Effective in in pretty much eliminating the pectus excavatum in in 23 of 73 patients. So it's something where it will frequently, we've been using the vacuum belt now for about 2 years, and we think that in patients who are young, who are under, let's say 10 years old, the vacuum belt can be very effective in lifting the chest up. Um, of course, many patients don't even develop a pectus until puberty, so, it, it doesn't take care of everybody, but there are also patients who have a minor degree of pectus who you wouldn't think, uh, was someone that you would think was, was, uh, the risk of operation was justified. Um, the use of the vacuum belt is a very reasonable thing to consider. And how does someone get access to that? I know that you said the company's in Germany. People can contact Mr. Kloby directly through the internet. Our office may be able to help people find it as well. Yeah, when I was down in Peru, I know that the surgeons down there were were very keen on the vacuum bell. Carlos Segura was using it. When would you prefer the Ravage procedure? Well, in, in, in patients who have a, uh, recurrent pectus excavatum following a previous ravageg operation, certainly a NS procedure can be done, and it will elevate the chest to some extent, but it really. Uh, won't do anything to, uh, restore the movement of the chest wall, uh, and the patients will, will have to some extent a restrictive process from the scarring that occurs after the ravage when it's when it's recurred and in some of those patients it's, it's worth, uh, thinking about whether a ravage operation would, would benefit them. OK, but almost never primarily. Yes, that's correct. Let's switch gears just to briefly go over pectus carinatum. Um, talk to me now. I know I did a lot of ravish procedures for this as a fellow, and I know now I pretty much am using braces. What, what is the The new standard therapy and what's the party line now in pectus carinatum because the 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. Um, there are some patients in whom one can know that it's going to fail. 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. Right, but for the For the most part, uh, it's, it's a good place to, to start, um, in, in, uh, patients whose chest wall is extremely stiff, however, it may be that the skin will break down before the brace and so, uh, that's worth taking into account also, um, do you, do you primarily use, uh, Marcello's dynamic brace or which one do you usually use? We, we generally use, uh, Marcello Ferro's, uh, uh, dynamic compression system and we had used, um. From the mid 1990s, uh, another, uh, sort of brace, and we found that that patients generally didn't wear it, and his brace solved the two objections that patients raised. One was that it is, uh, comfortable, uh, it can be adjusted so that the pressure is not too great, and the second is that it's concealable so that if the patient wears even an opaque t-shirt, it's close fitting and so people can't see they're having it to a teenage, uh, person, that's really an important thing. OK, we, we've been very pleased with the brace and it, and it works more or less 3/4 of the time in our hands. OK, um. And I think it's the MFM. I'm not remembering exactly the name, FMF, yeah, FMF. And uh, what about when is, uh, other than, uh, that one example you gave, um, who, who is generally a candidate and then what are the, is there any minimally invasive operation other than the ravage? Well, people who fail the brace are certainly a good candidate for the surgical treatment of pectus carinatum. When patients have a lot of symptoms, and most patients with carinatum do not, but there is certainly a small subset who do complain of pain and exercise limitation, I think those patients are people who should be considered for. Operation Patients whose chest is very stiff and they're and you uh try and embrace and they're just not making any progress, those are people to uh look at uh treating surgically. There is an operation, the so-called reverse Ns operation of Abramson. Uh, Horatio Abramson said, gee, if you can take a bar and push the sternum out, maybe I can put a bar in front of the sternum and pull it back. Uh, and, uh, we've used that operation here since 2008, and, uh, it, it does, uh, work well in patients with a flexible chest, um, so that's something to consider. The Ravage operation works well with Carotum, um. I have not seen or been made aware of a large series of operations for carinatum in which follow up is good and there isn't recurrence after operation for caratum, but there's a broad perception among people that have done a lot of ravage operations for caratum that there is an extremely low recurrence rate after that procedure as opposed to the 10% recurrence rate after an excavatum ravage. Um, so, um, so when, when patients particularly will, will say I don't want to have an implant, uh, I, I really don't wanna have to have a second operation to take out something, uh, the ravage operation in an older patient who is skeletally mature is, is certainly a very reasonable option. Yeah, that's, that's, I didn't realize the recurrence rate was that low. So Rob, that brings me to the end of the questions. Any other points that we should be hitting on? Interest in chest wall deformities is, is really an encouraging thing, and I think we are getting to the stage where people are beginning to ask why do these happen? Why is it that There is a family tendency in something like 40% of our patients, but the majority still don't have a family history. So why does somebody get pectus excavatum or carronotum to start with? Um, so hopefully we can get at some of the more basic questions that may help with answers to the surgical questions like, well, why is there a recurrence? But, but I think you have covered. A lot of the important things. So Rob, um, I know that your website is a wealth of information, and I want to direct the listeners there and that it's at www.chkd.org/nus, and again that's CHKD.org/nus, and I know there's a lot of information there. Also, go ahead and email any questions or referrals or any um. Things you want to bring up with Doctor Kelly at pectus.surgery at CKD.org. So I'm glad we're able to give the listeners, uh, all these resources. Also, I want to direct people to the phone number for your group, which is 757-668-8751. Again, that's 757-668-8751. I also wanna encourage the listeners to uh go ahead into the discussion forum, ask questions, uh, and uh we can make sure that uh Doctor Kelly and his team see those questions and can answer you. Um Doctor Kelly, I really appreciate your time. I know how, how busy you are. I appreciate you taking this time to educate all the listeners on some of the nuances of pectus disease. Well, thank you, Dr. Ponsky. It's a pleasure to be here. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current in Surgery app. Please send questions or comments to us attacurrent podcast@gmail.com. We'll see you next time.