Pectus Excavatum

Drs. Mikael Petrosyan and Timothy Kane discuss the most common chest wall asymmetry in children, Pectus Excavatum.  They discuss incidence, the work up as well as the treatment.  

Transcript

Intro 0:01

This is SURGUCATION, surgical education for parents. We are here to inform, inspire connect. Pectus Excavatum Surgery. episode 9, Dr. Ti mothy Kane, chief of general thoracic surgery at c hildren's national hospital.

Dr. Petrosyan 0:31

Hi, welcome to

Intro

Dr. Petrosyan 0:32

another episode of certification. I'm your host, Dr. Mikaell Petrosyan. Today we have Dr. Timothy Kane , as our guest , and we're going to discuss a diagnosis called pectus excavatum, which all it means is concave chest. We do see a lot of , patients , normally teenagers, and we do often see also, young kids, Tim and I do th ese p rocedures here at children's national hospital. And we wanted to talk about it a little bit, a nd, a nswer some questions that some parents may have welcome to certification, Tim. Al l r i ght. Why don't you tell our

What is Pectus Excavatum?

Dr. Petrosyan 1:08

listeners what is pectus excavatum?

Dr. Kane 1:12

So , pectus excavatum i s the most common chest wall asymmetry, it's where the chest wa ll i s c aved in, in a concave fashion. It's also called fu nnel c hest, a nd it affects one in three to 400 kids, mostly boys, three times more likely in males and females. It's something wh ere i t c ould appear at birth. but mos t, m ost commonly it appears in adolescents, i t associated with rapid growth spurts where one year the chest may look normal, but, an adolescent goes through a growth spurt in t he next year he has a big hole or a ca v ed in chest. So it's something that pediatrician frequently see and the time for referral is really when it's first noticed. And then we can an swe r questions related

Is This Hereditary?

Dr. Kane 1:59

to that.

Dr. Petrosyan 1:59

Is this hereditary?

Dr. Kane 2:01

Right, so there's no specific genetic link, but it's very common to be associated in families, parents, and children, brothers, sisters, brothers , can all have it. so although there's not a genetic link, it's very common to be found in families.

Dr. Petrosyan 2:16

Some

Is this a Cosmetic Operation?

Dr. Petrosyan 2:17

would argue that this is somewhat cosmetic operation. Do you agree with that?

Dr. Kane 2:21

I don't, there's data in the adult literature and in pediatric literature, which shows that there is a in improvement of the end diastolic filling volume of the heart cardiac MRI and intraoperative , right ventricular and left ventricular strain, with release or an improvement of the correction of the pectus excavatum. So we probably haven't done the correct studies yet to prove that objectively, but subjectively, In patients who are athletes before and after, a l most a hundred percent wil l sa y they have improved, u m , st amina and function. We're just working, on trying to prove, prove that in studies, but there's definitely a dynamic compression of the heart prior to pectus repair. If it's severe and improvement after in so me kids don't notice that they have decreased exercise tolerance because they, this has been there for a little bit time and they have n't really thought about it, but when they have surgery afterwards, maj o rity of our patients will say they feel better stamina. Correct.

Three Tests We Get for the Work-up

Dr. Petrosyan 3:25

So there are a few tests that we normally get when parents come to us and with kids who have pectus excavatum, these are three tests and three tests are, cat scan,

Dr. Kane 3:36

Cat scan basically , is the single t est you need just to document the severity of the chest wall asymmetry or the pectus. There are kids who, if it looks like a m ild asymmetry, , we don't order studies initially, or we'll wait u ntil they get older, because there's no need to get a study unless the family or child is interested in having a procedure, or if the practitioner thinks it's severe enough to warrant surgery on the other test to get as an echocardiogram, be cause t here's often some cardiac anomalies associated with five or so percent of pectus excavatum can be associated with a cardiac condition, w hich some down some time down the road may need some repair, like aortic root dilation or anomalous coronary arteries. In terms of a screening tool, our purpose of getting the cardiac echo is not to see if the pectus is ca using anything, but to rule out other sources, which cor rect on e day they may need a sternotomy to have that repaired. The other, the other tes t th at is not always done, but frequently is the pulmonary function tests. And those probably hav e th e lowest yield in terms of determining what to do surgically, because most of them are don't show any abnormalities, young, healthy teenagers. It takes a lot for them to have decreased lung function based on their chest wall. But some insurance companies request that I would say we get pulmonary function tes ts in le ss than 10%.

Dr. Petrosyan 5:03

Yeah , I agree .

Allergy Testing

Dr. Petrosyan 5:04

and then the other test that we normally get is , , allergy testing, which is important. it's became a standard of care recently to get the allergy testing because it, tests f or number of metals that are detected in the actual pectus bar. So there's two kinds of bars. There is titanium bar and there is a metal bar. The metal bar has and, I have a list of a number of stainless steel bar has number of metals in them. They can cause allergies, for example, n ickel chromium, molybdenum, manganese, silicon. So they all can cause, s ome sort of allergies. We don't want to place a bar in someone who has allergies to for example, nickel, then it causes a whole host of issues. Having a bar th at y ou are allergict to.

Dr. Kane 5:46

The issue is that with a allergy to stainless steel, we have to order a titanium bar, which are more expensive and require the custom bending. So , it's not the default to get that bar, but the testing pretty easy to do and much more accurate now. So it prevents the problems related to that bar allergy later on which requires steroid treatment, sometimes antibiotics, sometimes bar removal.

CAT scan and Haller Index

Dr. Petrosyan 6:09

And then just going back to the cat scan . Sometimes parents hear this term Haller index, which is basically a number that we look at to determine how severe pectus is . And there was also correction index where in some places who are not used to getting a cat scans with a correction index, the Haller Index may be actually low.

Dr. Kane 6:29

Heller index is based on a paper back in the late eighties, where they measured the widest diameter of the chest , and divided into that, the narrowest diameter between the back of the sternum and the sign here . And so that index, if it was above a 3.2 is considered severe and would benefit or qualify for surgery. And most insurance companies use that criteria. However, the Heller index can underestimate a severity of chest wall in kids who have really narrow chest and overestimate if they have really wide chest . So in 2012 ,

Correction Index

Dr. Kane 7:03

another index was published that shows , t he degree you need to correct the sternum to make it flat. And a correction index is gauged by a percentage. So if you have a 10% indentation in your chest, that you'll look at that individual and say that's fairly normal, s trike you.

Dr. Petrosyan 7:22

So anything over 10 is qualifies for , for essentially procedure.

Dr. Kane 7:26

for example, you can have someone with a correct , uh , Haller index of 2.8, but the correction next 26%, right? If you look at that individual, that's a severe one, but if you only use a Halloran, next sentence, not gonna qualify.

Dr. Petrosyan 7:37

I also think that kids who have actually normal Haller index those kids whose chest subjectively looks pretty severe while they may have a normal Haller Index. In my opinion, if they want to have the operation, they should have the operation because some kids are actually depressed. Itpsychologically causes significant pain and agony. They don't like taking their t-shirts off when they go to swim and whole host of issues. But emotionally they're just not doing well. So, a nd t he t imes insurances won't cover this procedure and w e have to call and argue with insurances and e xplained to them the situation with each patient. So, u h, while Haller index is sort of there for everyone to utilize, it's really not set in stone,

Dr. Kane 8:27

Right? And the insurance companies are much better now about, you know, accepting the correction index. A child can come in and we use the, depending on the age of the child, they may be very ambivalent. They don't care if their chest is indented . They're 12, 13 years old, 14. So those are children that we don't say you need surgery. You know, it's not, it's, there's no urgency. And typically those kiddos will come back with their parents in a couple of years. And they'll say, I don't like how my chest looks or it will progress over that period of time. , so that's why it's important not to get studies and tests if they're not thinking about potentially having the surgery, because it's the patient's choice. Uh, eventually we don't try to talk people into having the surgery. It's a commitment and it's , the child actually has to have skin in the game and say, yeah, I want to do this. You just have to be in on the decision as well.

Nuss Procedure

Dr. Petrosyan 9:20

All right, then , the operation itself takes about anywhere from an hour to 90 minutes

Dr. Kane 9:26

In involves measuring the chest and bending a bar, whether it be stainless steel that we bend ourselves or a titanium that is bent by a company, this is the standard width and diameter of these bars and you bend it to a convex position and then tunnel it behind the sternum, u h, from right to left. And then the anterior portion of the bar is going to be pushing the sternum out. And the bar will be behind the s ternum like this, and then laterally, it's going to be out outside the sternum, but along the chest wall, underneath the, u h, muscles and skin. And, you can, p ut these strategically in a position where the defect is lowest, b y using thoracoscopy, which is a camera, a n d you have direct visualization of the chest. Um, so the safety of that, i nc ludes being able to see the heart, being able to see the lungs and you tunnel the bar under direct vision. So you can avoid all the vital structures and put it in the best possible position. Cau se so metimes behind the sternum, there are kn obs of cartilage that if you blindly pass it through the bar may be unstable and pre disposed to subsequent bar tu rning and flipping them. And the other thing that we've done in the past few years is in kids with very significant indentations, very low, where you can't see the heart fully behind the sternum. We do sternal elevation to elevate the chest during surgery, to see safely, a nd to pass the bar. And in a lot of those individuals, probably 45- 50% will get more than one Bar.

Dr. Petrosyan 10:58

The bar itself

How Long the Bar Stays?

Dr. Petrosyan 10:59

stays.

Dr. Kane 11:00

Um , yeah, depending on age. We recommend if kids are over 18 or up to age, we do up to age 29, u m, two years at least. But in younger kids, we generally go towards three years, u m, because you w ant t o maintain that correction through growth spurts, u m, and not take it out too early. U m, and you also don't want to leave it in too long where you might impinge growth of the chest wall. And also the, u m, the placement of the bars or the positioning of the bars is important t o, to get an adequate correction. So the bar flipping occurs only about 1% of the time and, u m, it you'll lose your correction or it will look, u h, look different and that's a primary complaint of the child has,

Dr. Petrosyan 11:41

Or severe pain while they were doing fine . And now they have a severe pain . So those are the indications of something happened to the bar. So bar stays two to three years and then we normally take it out as an outpatient procedure. The actual hospital core is anywhere from two to four days nowadays.

Dr. Kane 11:58

Yeah, we , we have

Post Operative Pain Control

Dr. Kane 11:59

a protocolized pain , um, pathway such that our average length of stay, the kids go home on day three. Whereas when we, several years ago used epidurals, kids were here for five days , um, by their one to two week post-op checkup. Most of the kids was taking tylenol or motrin.

Dr. Petrosyan 12:15

I Think the lessons

Take Home Message for Parents

Dr. Petrosyan 12:16

for parents to take home are it's a treatable disease. it's treated b y operation. We normally get three tests. These ar e c at scans, a llergy testing, as well as, e cho echo cardiogram. The Halloran index over 3.25, usually qualifies for operation, but it's not set in stone. So if your child has a normal Haller index or Haller index that's below 3.25. You sti l l qua lify for the operation depending on your chil d's sit uation, correction and correction that 's as well. As Dr. Kane men tioned, both Dr. Kane and I do this operations here. If you have any questions and, wa nt to find out more information, please go to childrensnational.org. if you have further questions, please email us info@surgucation.com. Thank you very much and have a great day. Thanks Tim for coming and j oin i ng us.