Pectus Deformities: Update Course 2015

Psychosocial aspects of growing up are very important, and severe deformities should be fixed for psychosocial well-being regardless of symptoms

Insurance companies require documented symptoms and a Haller index for approval of pectus repair

Haller index of 3.25 originated from a retrospective study by Alec Haller in the 1980s comparing cases he fixed versus those he did not

The Haller index study was not an earth-shattering study at the time but has been used consistently for 30 years

There are approximately 14-15 reported cases of cardiac injury with the Nuss procedure worldwide

Thoracoscopy is not that helpful for cardiac injury prevention according to Kansas City's experience, so they do not generally use it

The subxiphoid incision technique involves making a small incision to insert a finger, removing the xiphoid process, lifting the sternum with a retractor, and feeling/guiding the bar as it passes above the heart

Transesophageal echo can be used to detect adhesions between heart and sternum, particularly useful in redo cases to avoid cardiac injury

A bone hook can be used through the subxiphoid incision to lift the sternum and gain an additional 1-2 millimeters of space for bar passage in deep deformities

A vacuum cup suction device is being used in Europe for pectus repair but is not approved in the United States

In Kansas City series of 168 patients over 6 years, there were 6 infections (3.6%), 5 required incision and drainage, 3 developed recurrent infections, and 1 required early bar removal

Kansas City has performed 503 pectus excavatum repairs using subxiphoid incision technique with no cardiac injuries

In Kansas City series of first 300 cases: 5% required two bars, 4% infection rate, 1.5% bar dislodgement or stabilizer discomfort requiring removal, 4 patients had bar rotation (early experience), 2 patients required chest tube, zero recurrences requiring reoperation, mean hospitalization 4 days

For pectus carinatum, dynamic compression bracing requires less than 7.5 PSI pressure to correct the defect for appropriate candidacy

Pectus carinatum bracing is typically worn 6-20 months, then transitioned to retainer mode (6-12 hours daily)

Currarino-Silverman syndrome shows a comma deformity on lateral X-ray and requires open Ravitch-type repair

Kansas City has braced 200 pectus carinatum patients with dynamic compression bracing and has performed very few (one or two) open repairs in the past 4 years

The dynamic compression brace costs approximately $1500-2000 total, requiring purchase of both a kit (one-time) and the device