Pectus Deformities: Update Course 2015

All right, let's, um, move on now to Doctor Holcomb, and, and I know that you're also doing a core, uh, you're doing a core topic as well, and you're gonna talk to us about pectus, right? So, uh, this is an interesting topic for us. We do things a little differently and so it might be, um, uh, helpful or interesting for folks in this country or around the world who are watching. Uh, this, uh, global cast, uh, to, to hear a little bit about the way we do things, uh, we do the operation in Kansas City, uh, at least for excavatum. So I'm gonna talk about pectus deformities and the most of the session is gonna be on excavatum and Carronotum, and then we might be able to have some roundtable discussion on the, the mixed defects. So, um, here's the first question. What are your, uh, as the surgeon criteria for repair, uh, if the child has symptoms irregardless of the severity, uh, will you, uh, uh, repair the excavatum, uh, if they have symptoms plus a Haller index of at least 3.0, is that, uh, good enough? How about symptoms, but a Haller index of 4, do they have to have a Haller index more than 3? Uh, or a Haller index of greater than 4 with or without symptoms. So I thought I'd, uh, I would just throw those out and see if anybody has any thoughts about them. We're putting that pole up, uh, while we're doing it. Um, any comments? Yeah, so, so what, um, if you could just classify the symptoms a little bit, is it they look bad, they feel bad, it's cosmetic, they don't want to go swimming with their friends. Are they short of breath? They feel they can't run as far as they usually do. Let's not say the cosmetic. Symptoms right now, but let's say respiratory symptoms, cardiac symptoms, uh, things like that, chest pain, chest discomfort. Because I actually believe that that the psychosocial aspects of of growing up are very important. And so if it's a really bad one, irregardless if they have symptoms or not, you ought to fix it for the psychosocial well-being of the child. That's just how many that's my personal insurance companies will allow you to do that. But you know where I am, they're only gonna allow you to do that if they have documented symptoms. And they'll also, you know, need a holler index. So how, how are these symptomatic? How many patients do you think have real symptoms? I'm not sure it matters. You ask the seriously, seriously, you ask the patient if they have the, you know, what kind of problems you have, what kind of symptoms, and they tell you. I mean, I, I, I do. I ask those questions, but rarely is there anything. So you know, rarely do they say, you know, do they have documented palpitations or that they're not necessarily keeping up with their peers and all those sorts of things. So I may not be cardiac output. I mean, I may not be asking the right, I may not be asking the right questions, number 4 here, you know. Well, no, and I did answer number 4 there, but I, but I guess I, I, you know, pain, I think some of them do have some real costochondral pain. And that can be an issue, but as far as the cardio respiratory symptoms, there are people that have spent their careers trying to prove something, and it's still, I mean, we can argue whether it's soft, clinically significant, or otherwise. Well, I think everybody sees, sees patients that that have a variety of symptoms or concerns or, you know, problems, and we sort of have to morph all that together along with their Haller index to figure out if they're a good candidate for repair. We were just, we just did a global cast on pectus deformities in Cincinnati children's, and they presented other scores, and now I'm forgetting what those were, but they didn't just use the Haller index. They had. Other indices that I'll have to look up and find out what those were, they're also doing functional MRI, um, cardiac studies, and they're looking at the contractility and the shift and the impact, uh, from that standpoint, and I think that's, yeah, I didn't add stuff like that because I didn't figure very many people were. Doing that we're doing that. So I just thought this was a basic question we started out with. And there's also the very deformed chest that has a normal Haller score because it has a discrepancy of both the combinations. So it's it's difficult. So I mean, so has Haller index ever been clinically correlated to why we use those numbers, or is this just arbitrary that we say 3 or 4? He, he wrote, Alec Howell wrote a paper back in the 80s that Uh, he tried to correlate severity with the CT scan, the Haller index, and as I recall, the severity, I think he came up with it on his own that it was 3.25, right? And, and ever since then we had just used those numbers, used that number, but it might have even been a retrospective study where. Oh, it was the ones that he fixed versus the ones that he didn't and that's how you got the numbers. So it was a retrospective, yeah, so and in fact it was, I, uh, Doctor Howard's a good friend of mine. I, I hate to say this, but it was, it was not an earth shattering study at the time, but 30 years later, you know, we use it all the time. Right, so I just, I just don't get that, that number because it's, it's arbit it's it's arbitrary when you have these patients and they come in and they have symptoms, so they say I get chest pain, I can't keep up with my peers, or I'm having, you know, shortness of breath. Besides the CT to look at the Haller index, what other studies do you do? Do you get a cardiology consult? Do you have them see a pulmonologist, um, or you just say, OK, go with the CT and your symptoms and move forward? Well, if, if they had a, if they had those symptoms and they didn't have a significant practice, then I would go to a pulmonologist and a, or, or a and a cardiologist. If they have a significant practice and those symptoms, I generally don't do that, and I do. Um, um, because I'm concerned about the documenting that I'm relieving the symptoms related to the surgery, and while invariably those studs, those consults come back, um, as normal except for, you know, the anatomical things that they see, I think that I'm obligated to make sure they don't have some element of reactive airway disease or some other cardiac issue that, um, I would not be addressing by doing a pectus reprint. Well, let me go on and get on and move on. Um, and well, those are, um, being tabulated, so here's another question. This is about nickel allergy, and I'll be honest, 15 years ago, uh, or 20 years ago, I didn't, I don't think many of us gave much thought about nickel allergies with our pectus bars, but it's, it can be a real, uh, significant problem, especially if you, if you, uh, put a bar in that has nickel, uh, in it and the child gets an allergic reaction to it. So here's the question. Uh, do you always test your patients, uh, uh, for nickel allergy? The, uh, that's #1. Yes, every, everyone gets testing. Number 2, sometimes depending on answers about nickel and metal allergies that you give them, uh, or number 3, you've never had this problem, so I don't test for nickel allergy. So the polls are coming in. Um, so far, 60, it's rapidly changing, but 65% here to say sometimes. OK, what we do, we have a, um, a questionnaire that we give these families. We'll have them fill it out and we look at it, uh, and then if there are answers concerning answers on the questionnaire, then we do test the family. We don't test every patient for nickel allergy. OK. Do you know if you've missed, do you know how, how well that works? Is that? I have not had a problem with this. I think one of my partners thought he may have had one, but treated with antibiotics and it got better. So, so the screening seems to work. Screening seems to work, and actually this is the, we use the same testing that, that, uh, our colleagues in Norfolk use. Um, so once you've decided on a repair, which technique do you use? Uh, do you prefer the open, uh, repair, the so-called ravageg operation, the minimally invasive repair, the so-called nus operation, or is there another operation that you prefer? Again, another poll question. Uh, and I'll put other just to be inclusive in case there's something, uh, else that, uh, some surgeons utilize. So it's becoming almost all, I mean, high predominance of nuts, OK, um. So here's a question that I, uh, I've thought about, uh, over the last number of years. So how do you try to prevent infection with the nus repair? Seems to me the nus repair is a very good operation, uh, but infections are real, can be a real problem post-op. So here's several answers. There may be more than one answer that you use, and that's fine. So number 1 is nothing special. I just prep carefully. Number 2 is I prep twice. Number 3 is I give them IV antibiotics one pre-op dose. Number 4 is I give them IV antibiotics one pre-op dose and then for 24 hours. Number 5 is a pre-op dose and then 2 days or longer of IV antibiotics. Number 6 is a double glove. And number 7 is I place an o band drape, sterile drape over the sterile field after I prep. It would be great to have a last choice called more than one. But so this is while folks are answering that question, uh, this is just what I, uh, do the, uh, in the left upper, uh, part of the screen. I like to place a, uh, a, uh, vertical roll underneath the, uh, child's back to really get them elevated above the operating table so that I can then prep widely and I don't skimp on the, the lateral prep, uh, but I like to try to get underneath the, uh. You know, around the posterior axillary line, uh, and it helps to place the vertical roll underneath the child to do that. uh, then, uh, prep, uh, still old fashioned, uh, and, uh, you see some staples that have been put on the uh drapes to keep the drapes from sliding out. I also I double glove and, and, uh, many of you may as well, and then I place this ale band drape or sterile drape over the field. So I try to do. Everything I can to prevent a postoperative infection. What do you guys screen for MRSA? No, not right now. Excuse me, not routinely if there's some. We, if there's some something that raises that question, then we will, but we don't, we don't do nasal swabs or anything like that. Uh, here's an operation, uh, or excuse me, here's a question. How do you avoid the cardiac injury? There are about, I don't know, 14 or 15 reported cases, um, uh, uh, around the world, uh, of cardiac injury with the nus. So I don't do anything special is the answer number 1. I just use slow, careful technique. I sometimes use thoracoscopy is number 2, depending on the severity of the problem. I always do thoracoscopy on the left side. I always do thoracoscopy on the right side. I do thoracoscopy on both sides. Uh, I use a sub xiphoid incision and don't use thoracoscopy. That's our particular answer in Kansas City, and I use some other technique. So I thought we'd try to get poll results on that. Um, I'm getting Interesting. My, OK, I, so first of all, most, almost everyone, it looks like the right side, I can't see the choices on my uh phone, Mark, but it looks like it's the right side that almost everyone is saying. Yeah, no, Thrakowsky always on the right side, right side is the one that's. So just. Does anybody put the bar in left to right? So we actually changed it. Because I think a lot of people put it in right to left. I think left to right with the heart, you know, the heart right there, once you get past the heart, not that it's, you know, you just have a little bit of level of comfort, but going, doing that first, and if you're going to use thoracoscopy, we use, we do it based on the severity. And if it's a deep pectus, we'll put a scope in, but then you see the heart where it's coming across the heart and over it, and then the right side should be less risky than the left. So I'm surprised everyone's doing right thoracoscopy unless they're, unless they're going right to left with the bar. So our feeling in Kansas City is that thoracoscopy is not that helpful, and, and so we don't generally use thora, we don't use thoracoscopy. Um, but I think everyone around the world. Outside of Kansas City actually does use thoracoscopy and I'm just gonna show you the this little um. This is about a minute video. Of our technique, so we make a small incision in the subxiphoid region just big enough to get your finger in. Uh, usually take the xiphoid process out, uh, take a retractor and lift up the, uh, sternum, uh, and then we have our finger in and we're feeling the bar as it's going through. Let's see. We're feeling the bar as it's going through. Uh, the intercostal space, uh, and we sort of guiding the bar, uh, above the heart, uh, and then we bring it out the subxiphoid incision. And um Uh, and then do it the other side. But anyway, at least in our, in our, uh, uh, experience, it's the safest way to avoid a cardiac injury. So you bring it out, the subxiphoid incision, and then what? And then we put a A tape on it and bring that and then bring that out so we, we bring the bar through the sub xiphoid incision from the left side as you're seeing there past two tapes into the uh bar passer and bring it out the left side and then uh take the same bar passer and place it from the right incision out the subxiphoid incision, connect the tapes, and then we have the tapes going all the way across. And then we tie the, uh, bar to one of the tapes, feel it as it's coming across the mediastinum and then out the other side. Uh, and so anyway, uh, I'll show you our results here, um, in a few slides, but at least for us it's the safest way to avoid the cardiac injury, and that's why we make the subs I4 incision. We can get that video later. Yeah, yeah. The only other technique I've heard about, um, and this, I think is primarily with redos, and I don't do this operation, so, uh, but may have come up when you had the show. Uh, so I guess there's some experience, especially with redos of using, um, uh, endoscopic ultrasound or, uh, cardiac ultrasound to look for adhesions between the, the heart and the, and the sternum, because I think that some of those cases of cardiac injury have come from. Uh, where the heart is tethered, and you can tell that, um, using a transesophageal echo. I wouldn't, I don't think you need to do that on every case by any stretch of the imagination, but it's the only other technique I've heard on other than what you've already mentioned in terms of things to do to try to avoid injury and a real deep one, if you can take a bone hook and, and through the subxiphoid incision, lift the sternum up, it gets you maybe another 1 millimeter or two. Space to pass the bar as well so that's another adjunct, uh, that you can sometimes use. We generally don't use the bone hook we generally use our finger, but it's just, it's another. Uh, aid. There's a suction valve in Germany that's right, and that's placed on the chest to suck it up and then pass the bar with or without the bar, but it's, yeah, I, I think that's, uh, I don't think that's approved in our country to use it or not, but, uh, I saw a recent paper from Europe about that, uh, and they seem to have good results. Um, here is another question. How do you manage postoperative pain? Uh, number one, always use IV, uh, analgesia. That is in our country we call this patient controlled analgesia. Uh, always use an epidural, uh, use an intercostal block, place an infusion catheter into the thoracic cavity on one or both sides, uh, or something else. I thought it'd be interesting to see how, how folks, uh, around the world manage their pain. Uh, at the same time, I thought I just show the study that came from our uh hospital that um uh Sean Saint Peter was the uh PI on uh uh came out a few years ago, randomized 110 patients to epidural or PCA. The epidural group had a longer time in the OR and that's because it took a long time to place the epidural catheter. There were more phone calls to anesthesia compared to the PCA, and there were. Um, greater hospital charges, and that's because of the longer OR time and the longer OR charges. The pain scores generally favor the epidural group. The 1st 22 days, the third day there was generally, uh, uh, they were generally flat, and then the last uh couple of days favored the PCA. Uh, interestingly, and this is a, uh, I think, uh, an, an important finding is the epidural catheter was removed within 24 hours or it could not be placed in almost a quarter of the patients. And these were done by uh by experienced anesthesiologists and a select group of anesthesiologists who participated in the study, so not all epidural catheters work. Uh, getting back to the infection question, uh, by the way, we have that video if you want to show it. Yes, we'll show the video. So let's roll the video here. So again, this is the It's a, you know, it's, it's the incision's a couple of centimeters, uh, big enough to get your, uh, finger in there lifting the sternum up with a retractor, and then we're gonna place this, uh, uh, bar passer out through the subxiphoid, uh, incision, place two, tapes on it. And bring it out and then we, uh, do the same thing from the other side. And now we've got the tapes across the mediastinum. It's tied to the bar and we're, we're feeling the bar go uh, over the heart through the mediastinum, then out the other side, uh, and, uh. And then we We aspirate as we're closing we uh Valsalva and aspirate, uh, any air that's left in there. Um, I need some Zantac. So here's a, uh, I, I think management of postoperative infections can be difficult, uh, and so here's a paper that came from our place, uh, about 10 years ago, uh, and we had 6 infections over about a 6 year period, uh, 6 infections out of 168 patients at the time, 5 of them required incision and drainage. Uh, 3 of the 6, developed recurrent infections, and of those. Uh, that were developed in recurrent infection. One of them had to have their bar removed early. So, uh, anyone who's had to deal with a post-op pectus infection knows it can be difficult to manage. And so you try to do everything you can not to, not to develop a postoperative infection. Here's an interesting question, because this is Uh, this happens not infrequently, and that is the patient has rib flaring postoperatively, and sometimes it's on both sides, sometimes it's just on one side, and so the question is what do you do about uh rib flaring? One answer is, uh, I don't do anything. Another one is use a binder and this photograph shows a child that a binder's been placed to see if that works. Uh, a 3rd answer would be excise the costal margin before you remove the bar, and then the 4th would be you excise the costal margin at the time of bar removal, so. I'm interested to, uh, to see how our Our colleagues respond to that one. Um, at some point I want to, there's, there's poll results and some comments from the audience we can do. You wanna do that now, or because they're not all, some of them are from previously, but, um, number one, Cynthia Reyes. Hey, Cynthia, she's, we, we love having her here. She's always present. Um, have you had brachial plexus injuries with the positioning? I have not. OK. Has anyone? OK, um, you do, you do have to be careful about not extending the arms too much, uh, but I've, I've not had that problem. OK, uh. Um, does the force elevation of the rule tract allows excellent avoidance of the cardiac injury, she's just making a comment. Edgar Rubio says, do you consider the availability of having a cardiac surgeon nearby as a prerequisite in order to do the operation? No, anybody. No, that's a significant issue and had become a significant issue for us because the question is whether these could be done at an outside facility, not at the main children's hospital where there's the potential for putting somebody on bypass or having a cardiac surgeon immediately available. So you do have that prerequisite. That's why they're done at the main institution, correct? Got it. That's an interesting point, um. And someone, uh, uh, Pascal, uh, mentions that he has had a cardiac injury, um, from a broken rib when they inserted the instrument because there was some pathology under the sternum, uh, so those are some of the comments and then the poll results, um, so most people do nothing for, which is funny because it started off mostly binder, but it's most people do nothing for, uh, the rib flaring. OK, 70%. Is that the consensus here? I, I do what the, I, I, I don't do anything for 3 years. We didn't, we take the bar out in 3 years, but whenever you take the bar out, if the family wants something done, uh, then you can do it at that time. Generally speaking, they don't necessarily want anything done because the rib flaring is not as bad as the pectus was, and their pectus looks really good, and so they're really happy about that, OK. All right, so here's the question is how long do you leave the bar? Answers are 1 year, 2 years, 3 years, and 4 years. And here's a patient, uh, excuse me, here's a paper from Doctor Nuss's group, uh, that reviewed, I think this is their most recent paper, uh, 1987 to 2008, 1200 patients, and incidentally they had a nickel allergy, um. Uh, frequency of 2.8%, almost 3% in their patients had nickel allergy. Uh, now in this slide right here, they found that the results were better if we If the barrow was left in at least 2 years, and I'm trying to If you see this line right here is 18 to 23 months. And this is 2 years. Uh, 3 years. Uh, 3.5 years. And so the results, uh, it may not show up very well. The results were considered better if the bar was left in in, uh, 24 months. Uh. Dr. Nuss, uh, has, uh, I've, I've talked to him several times about this, and he feels the results are better if they're left in 3 years. And so we have generally speaking left the bar in for 3 years, but certainly 2 years is, you need to leave the bar in for 2 years. Well, there's a complete split, 3 or 2, but almost everyone does at least 2, yeah. And I think that's the important point. Uh, this, uh, slide right here just shows our experience. Uh, I've looked at the numbers recently, we've done 503, uh, practices with this sub xiphoid incision technique. Uh, in 2010 we published our experience with the 1st 300, and you can just run down the list. We 5% required two bars. We had 4% infection. We do put stabilizers in on both sides. I realized that, uh, many don't put stabilizers in at all, and you may use wire or strong suture. Some put them a stabilizer on one side but not the other. Uh, but we have put it, uh, we put it on both sides, uh, and we've had 1.5% of bar, uh, uh, dislodgement or stabilizer discomfort requiring removal, and that was generally in the early part of our experience. Uh, uh, 4 patients had their bar rotate. That was also early in our experience. Uh, a couple of patients had a chest tube, so 2 patients out of 300 is not too bad. Uh, for requiring a chest tube, we've had no recurrences requiring reoperation, no cardiac injuries, and the mean hospitalization's been on average 4 days. So just a snapshot of our experience in Kansas City, and I will, uh, there, there are a number of surgeons who do this. I think they're. There are probably 8 or 9 surgeons who've been involved in all of this, and there are 5 or 6 of us who do these operations now, so. Uh, Uh, a number of surgeons doing them. Just to mention, Tony mentioned about this vacuum cup suction, uh, down here is another technique. It is being used in Europe some. Here's something called the magnetic mini mover procedure 3MP. This slide came from Corey Iqbal, one of our surgeons who presented, uh, uh, an update on this at ABSA last year. The idea is that uh the patient wears a magnet uh outside of uh or a magnet escorpoly. A magnet is then implanted uh on the sternum and that the uh uh sternum is then lifted forward uh through the uh magnet. And here's a, this is, this is an early prototype. It's not exactly like it is now, but this little bar right here is uh placed underneath the sternum. This is anterior on the sternum, uh, and that's the magnet that attaches, and this is what it looks like now, and this is the patient wearing the uh uh the uh external magnet, uh, and it's, it's really there's an FDA trial going on now. It's 18 months into the trial. All patients have been implanted, and I think there's another 18 months, uh, 18 months, according to Corey, of data collection before the trial will end. So just wanted to, um, Update on a couple of new techniques. Great. Pectus carinatum. We just, by the way, so we're over about 20 minutes, so we'll probably try to wrap it up. OK, so this is the easily the most common one right here is the chondrogladiolar, uh, which is the lower part of the sternum, uh, sternum. This is the chondromanubrial. This is a classic picture of the Corino Silverman syndrome. Uh, and if you see something that looks like this, this is not a pectus excavatum, uh, but it's a pectus carinatum. Uh I'll, uh, here's a couple of slides, I mean, a couple of questions. I'll just, uh, yeah, we could put the polls up, Jenny, but, OK, yeah, and there's some questions from the audience, I put it up and, but, uh, just go, we can talk fastly about it and we can look at the polls later, OK. The first question is about how do you manage a mild to moderate pectus carinatum. The next question is about how do you manage a severe pectus carinatum. Uh, the third question is, if you do brace, which do you use? Do you use a brace that is made in your own hospital or in your city, uh, or do you use this dynamic compression brace that, uh, Marcelo Martinez Ferro and his colleagues in Argentina make, which is the one that we use. Uh, the advantage of this particular brace is it allows you to identify the pressure needed for correcting the defect. It gives the measurement in pounds per square inch. Uh, and if there's less than 7.5 PSI needed to correct the defect, uh, then it's an appropriate one to brace. Uh, and this, uh, you, so you place the brace on, you can then see how much pressure is being exerted by the brace in this particular slide right here, 2.5 PSI are being used, uh, but this is the way it actually looks, uh, on the patient. We recommend wearing the brace as much as possible. Usually you wear it 6 to 20 months, and then we go into at some point into what we call retainer mode, much like a retainer for braces that you may wear it 6 hours, 12 hours a day, something like that. Um, and here's just a slide. I thought I'd show you. This is another young lady with the Carina Silverman syndrome, and below is a paper from uh Bob Shamburger and Ken Welch from the late 80s, which is uh probably uh remains one of the best papers about management of this, of these uh kids. But you see on the lateral X-ray on these patients, you see this is called a comma. Uh, sort of a comma deformity if you will, um, and, uh, this is a difficult one to, repair and it needs to be repaired with an open ravageage type of procedure and this is a good ref the papers a good reference for how to do the operation. Also, I'll mention that Doctor Abramson in, uh, Buenos Aires, uh, has, uh, devised a minimally invasive operation for pectus carinatum. Here are two, papers. The first one is, uh, I think it's his initial paper, at least his initial paper in the English language on a five year experience with, um, uh, his operation for pectus care notum. And then below, uh, his paper is a paper from, uh, uh, our, uh, colleagues in Norfolk about stage management of pectus car autum including bracing, uh, and also the use of the, uh, Abramson procedure. And then here's a slide of talking about just showing about uh mixed effects so that's uh Todd, that's all I have. Great, perfect. Um, I, I think that for the sake of time, um, just one comment is that when you went from mild to severe, almost everyone braced, and then when you went to severe, it became that 33% due to ravage. Um, most people, as you would expect, have to make their own braces. Um, who here has used the dynamic impression? Marcello's, uh, device. Do patients have to pay for that? I think that was an issue. The way that we do, we've actually braced. I was looking at these numbers for our cane. We've braced, uh, 200 patients with the dynamic with the dynamic compression bracing. Uh, what we have done is the hospital, um, buys the brace and then the hospital bills the patient. Some people might have the, the. Marcello's company can't really bill the patient. Uh, it's difficult for the collection of funds or bill the insurance company, so we bill the insurance company for the brace. And does the insurance company cover it? The, um, uh, I'm blanking on it. I think it's around $1500 maybe $2000 and you have to buy two things. You have to buy the kit and then the which is a one time, and then you buy the device. Right, well, for my nephew, I'm given the total, the total cost of, I, I think that's about right. All right, I will tell you it's a very effective way to, to resolve a pectus carinatum. We've been very satisfied and I'm not sure we've done a single. Open repair since we started bracing 4 years ago. We may have done one or two, but, but it's been a very low numbers. So, so you checked the dynamic compression ability or the flexibility of the sternum, and you have not found a case that you could not break. That's correct. And their recommendation is a PSI of correction of less than 7.5. Any last comments or questions about this topic before we move on? Thank you, Whitt. That was great. And feel free to continue putting your poll, your uh questions in, and uh, I'm sure Whitt can answer them.