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 physical symptoms

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

Rarely do pectus patients have documented palpitations or clear evidence they are not keeping up with peers in terms of cardiac output

Some pectus patients have real costochondral pain that can be a surgical indication

Cardiorespiratory symptoms in pectus patients remain debatable regarding clinical significance despite careers spent trying to prove their importance

Some severely deformed chests have normal Haller scores due to combined anterior-posterior discrepancies

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

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

Pulmonology and cardiology consults are obtained when patients have symptoms without significant pectus deformity to rule out reactive airway disease or other cardiac issues unrelated to pectus

Documentation of symptom relief related to surgery is important for insurance purposes, requiring workup even though consults typically return normal except for anatomical findings

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

Passing the bar left to right (rather than right to left) may be safer because once past the heart on the left, the right side has less cardiac risk

In deep pectus cases, thoracoscopy shows the heart where the bar crosses over it, making the right side less risky than the left

Thoracoscopy is not that helpful for cardiac injury prevention according to Kansas City experience, though most surgeons worldwide outside Kansas City use thoracoscopy

The subxiphoid incision technique allows finger guidance of the bar across the mediastinum above the heart, which the Kansas City group considers the safest way to avoid cardiac injury

Transesophageal echo can identify adhesions between heart and sternum, particularly useful in redo cases where cardiac injury risk is higher from tethering

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

A suction valve device in Germany is placed on the chest to lift it and facilitate bar passage, 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

Rib flaring occurs postoperatively, sometimes bilaterally or unilaterally, and most surgeons do nothing about it

When bars are removed at 3 years, families generally do not want rib flaring addressed because the pectus looks good and rib flaring is not as bad as the original deformity

Kansas City series of 300 pectus excavatum repairs using subxiphoid technique: 5% required two bars, 4% infection rate, 1.5% bar dislodgement or stabilizer discomfort, 4 patients had bar rotation (early experience), 2 patients required chest tube, no recurrences requiring reoperation, no cardiac injuries, mean hospitalization 4 days

Dynamic compression bracing for pectus carinatum is effective when correction requires less than 7.5 PSI pressure

Brace wearing is recommended for 6-20 months followed by retainer mode (6-12 hours daily)

Currarino-Silverman syndrome shows a characteristic 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 only one or two open repairs in the past 4 years

The dynamic compression brace costs approximately $1500-2000 total (kit plus device), billed through the hospital to insurance