Because 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.
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.
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.
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.
clinicalCommon presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally not occurring at rest but with exertion.↗
▶Ep 5 · 1:33
quoteWhen 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.↗
▶Ep 5 · 2:55
clinicalBoth Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.↗
▶Ep 5 · 3:44
quoteIt'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↗
▶Ep 5 · 4:04
clinicalIn a normal chest, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner).↗
▶Ep 5 · 4:19
quoteThe 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.↗
▶Ep 5 · 4:29
clinicalIn pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath the xyphoid pulls back towards the spine.↗
▶Ep 5 · 6:05
epidemiologicalIn a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.↗
▶Ep 5 · 6:36
clinicalWhen both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first.↗
▶Ep 5 · 8:39
epidemiologicalIn the multi-center study of pectus excavatum at 11 centers, roughly 2/3 of patients had symptoms of easy fatigability, shortness of breath, or chest pain.↗
▶Ep 5 · 9:44
clinicalThe Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine; an index greater than 3.25 indicates severe pectus excavatum.↗
▶Ep 5 · 10:09
clinicalThe Kansas City group recognized that in a patient with a barrel chest, the Haller index underestimates the depth of the depression because the AP diameter is increased, and they advocate an alternative index comparing the AP distance at the depression to the normal lateral chest.↗
▶Ep 5 · 12:53
epidemiologicalMitral valve prolapse is present in about 14% of pectus excavatum patients, compared to about 1% in young patients generally.↗
▶Ep 5 · 13:37
epidemiologicalOn average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).↗
▶Ep 5 · 14:15
clinicalPatients with pectus excavatum came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored through surgery.↗
▶Ep 5 · 14:37
clinicalRestrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is seen in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.↗
▶Ep 5 · 15:05
clinicalPatients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.↗
▶Ep 5 · 15:11
guidelineSurgical indications for pectus excavatum include at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests <80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, and major psychosocial issues related to body image.↗
▶Ep 5 · 16:47
clinicalThe ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty (ages 11-13 for girls, a year or two older for boys).↗
▶Ep 5 · 17:02
clinicalHaving the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.↗
▶Ep 5 · 17:29
clinicalSome Asian groups, particularly in Korea (Dr. Park), operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.↗
▶Ep 5 · 17:55
quoteIt'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.↗
▶Ep 5 · 18:32
quoteThe 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.↗
▶Ep 5 · 18:32
clinicalThe hard part of pain management is not to relieve the pain, but to relieve the pain without obliterating consciousness, which requires feedback from the patient.↗
▶Ep 5 · 19:13
quoteWe'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↗
▶Ep 5 · 20:03
clinicalAbout half of pectus excavatum patients don't have their usual appetite after surgery, while about half eat very well.↗
▶Ep 5 · 20:46
guidelineFor the first month after pectus excavatum surgery, patients should only walk and do activities of daily life; beginning at 1 month they can liberalize physical activities; by 3-6 months they can do pretty much any activity except those where they know they'll get a blow to the chest.↗
▶Ep 5 · 21:09
quoteI 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.↗
▶Ep 5 · 21:40
clinicalThe Allergies test developed in Canada includes all components of the stainless steel bar, and patients have reacted against a number of minor components including nickel, chromium, and cobalt.↗
▶Ep 5 · 22:17
clinicalTitanium bars must be bent at the factory and have to be ordered in advance; they are currently much more expensive than stainless steel bars.↗
▶Ep 5 · 22:45
clinicalThe likelihood of transfusion in Nuss procedure is exceedingly low.↗
▶Ep 5 · 23:29
clinicalMeasuring the bar length from mid-axillary line to mid-axillary line and subtracting an inch is one method that works very well.↗
▶Ep 5 · 24:43
quoteI think 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.↗
▶Ep 5 · 24:43
guidelineIt should be standard practice in patients with any difficulty in visualization to use some technique of sternal elevation during Nuss procedure.↗
▶Ep 5 · 26:02
clinicalThe most important part of the Nuss procedure, whatever techniques are used, is that the surgeon sees the tip of the introducer at all times—not just knowing it's in there somewhere, but actually seeing it—to minimize the likelihood of injuring the heart.↗
▶Ep 5 · 26:02
quoteThe, 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.↗
▶Ep 5 · 28:54
clinicalThe bar must be positioned medial to the pectus ridge so there is a rib providing counterforce; if placed very laterally, only the intercostal muscles prevent movement and they will strip or rip under the load.↗
▶Ep 5 · 28:54
quoteIf 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.↗
▶Ep 5 · 30:07
clinicalIn patients who are growing, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so they are generally placed on only one side.↗
▶Ep 5 · 30:39
clinicalIf a patient is over approximately 6 feet 2 inches tall, the chances of needing two bars are almost 100%.↗
▶Ep 5 · 33:03
epidemiologicalIn multiple series, short-term complications of the Nuss procedure are few and intervention has been infrequent.↗
▶Ep 5 · 33:14
epidemiologicalIn a series of past 2000 Nuss procedures, about 2.7% of patients required some sort of revision for bar displacement.↗
▶Ep 5 · 33:28
clinicalThe incidence of bar displacement has been cut to about half (approximately 1.35%) by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.↗
▶Ep 5 · 33:43
clinicalMost bar displacement now occurs due to some kind of marked force or trauma rather than spontaneous displacement.↗
▶Ep 5 · 34:13
epidemiologicalBar allergy occurred in a little less than 1% (0.9%) of patients; screening for metal allergy has been performed since 2004 and has dramatically decreased the incidence.↗
▶Ep 5 · 34:27
epidemiologicalAbout 6.4% of pectus excavatum patients had clinical or patch test evidence of metal allergy.↗
▶Ep 5 · 34:40
epidemiologicalWound infection occurred in 2.3% of patients, with more than 2/3 being superficial or cellulitis.↗
▶Ep 5 · 35:07
epidemiologicalRecurrence after Nuss procedure occurred in about 1.2% of patients.↗
▶Ep 5 · 35:16
opinionWhy recurrence happens after pectus excavatum surgery is still poorly understood; it can occur even when the bar is left in for 3 years.↗
▶Ep 5 · 36:39
guidelineThe bar should remain in place for at least 2 years before removal, with preference for closer to 3 years than 2 years.↗
▶Ep 5 · 37:19
epidemiologicalIn a study from Saint Etienne, France published in Journal of Pediatric Surgery, vacuum bell treatment was effective in pretty much eliminating pectus excavatum in 23 of 73 patients.↗
▶Ep 5 · 37:58
clinicalIn patients who are young (under approximately 10 years old), the vacuum bell can be very effective in lifting the chest up.↗
▶Ep 5 · 39:06
clinicalIn patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore movement of the chest wall, and patients will have some restrictive process from scarring.↗
▶Ep 5 · 40:04
epidemiologicalBrace therapy for pectus carinatum is successful somewhere between 2/3 and 3/4 of the time.↗
▶Ep 5 · 40:27
opinionBecause any operation carries more morbidity than almost any brace, it's hard to say one shouldn't start with brace treatment for most patients with pectus carinatum.↗
▶Ep 5 · 40:46
quoteI 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.↗
▶Ep 5 · 41:23
clinicalMarcello Ferro's dynamic compression system brace solved two patient objections: it is comfortable (pressure can be adjusted) and it's concealable under even an opaque close-fitting t-shirt.↗
▶Ep 5 · 42:00
epidemiologicalThe Ferro brace works approximately 3/4 of the time in Dr. Kelly's experience.↗
▶Ep 5 · 42:43
clinicalMost patients with pectus carinatum do not have symptoms, but there is a small subset who complain of pain and exercise limitation who should be considered for operation.↗
▶Ep 5 · 43:13
clinicalThe reverse Nuss operation (Abramson procedure) works well in pectus carinatum patients with a flexible chest.↗
▶Ep 5 · 43:43
opinionThere is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.↗
▶Ep 5 · 44:52
epidemiologicalThere is a family tendency in pectus deformities in approximately 40% of patients, but the majority still don't have a family history.↗
Chest Wall Deformities with Dr. Robert Kelly
▶Ep 12 · 1:33
clinicalCommon presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest.↗
▶Ep 12 · 1:33
quoteWhen 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.↗
▶Ep 12 · 2:55
clinicalBoth Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.↗
▶Ep 12 · 4:04
quoteA 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.↗
▶Ep 12 · 4:04
clinicalIn patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration.↗
▶Ep 12 · 4:29
clinicalIn pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath.↗
▶Ep 12 · 4:29
quoteWhat 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.↗
▶Ep 12 · 6:15
epidemiologicalIn a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.↗
▶Ep 12 · 6:15
quoteIn 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.↗
▶Ep 12 · 6:36
clinicalWhen both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon.↗
▶Ep 12 · 8:39
epidemiologicalIn the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain.↗
▶Ep 12 · 9:44
clinicalThe Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus.↗
▶Ep 12 · 12:53
epidemiologicalMitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population.↗
▶Ep 12 · 13:37
epidemiologicalOn average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).↗
▶Ep 12 · 14:15
clinicalIn both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery.↗
▶Ep 12 · 14:37
clinicalRestrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.↗
▶Ep 12 · 15:05
clinicalPatients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.↗
▶Ep 12 · 15:11
guidelineDr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image.↗
▶Ep 12 · 15:35
clinicalAround the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct.↗
▶Ep 12 · 16:47
clinicalThe ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that.↗
▶Ep 12 · 17:02
clinicalHaving the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.↗
▶Ep 12 · 17:55
quoteIt'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.↗
▶Ep 12 · 18:32
quoteThe 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.↗
▶Ep 12 · 18:49
clinicalDr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback.↗
▶Ep 12 · 19:13
quoteWe'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.↗
▶Ep 12 · 19:39
clinicalDr. Kelly's center has not used epidurals for pectus excavatum surgery for several years.↗
▶Ep 12 · 19:47
clinicalPostoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery.↗
▶Ep 12 · 20:46
clinicalFor the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest.↗
▶Ep 12 · 21:37
clinicalThe Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance.↗
▶Ep 12 · 22:17
opinionTitanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate.↗
▶Ep 12 · 24:43
quoteAt 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.↗
▶Ep 12 · 24:43
guidelineFor Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other.↗
▶Ep 12 · 24:57
clinicalSternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify.↗
▶Ep 12 · 26:02
quoteThe, 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.↗
▶Ep 12 · 26:02
clinicalThe most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low.↗
▶Ep 12 · 26:43
clinicalTo prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib.↗
▶Ep 12 · 27:32
clinicalFor Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus.↗
▶Ep 12 · 27:39
clinicalIn post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient.↗
▶Ep 12 · 28:54
clinicalThe bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load.↗
▶Ep 12 · 28:54
quoteIf 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.↗
▶Ep 12 · 30:07
quoteIn 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.↗
▶Ep 12 · 30:07
clinicalIn growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar.↗
▶Ep 12 · 30:39
clinicalPatients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation.↗
▶Ep 12 · 31:17
clinicalThe Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities.↗
▶Ep 12 · 32:02
clinicalPostoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines.↗
▶Ep 12 · 33:14
epidemiologicalIn Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.↗
▶Ep 12 · 33:43
clinicalMost bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents.↗
▶Ep 12 · 34:13
epidemiologicalBar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy.↗
▶Ep 12 · 34:40
epidemiologicalWound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle.↗
▶Ep 12 · 35:07
epidemiologicalRecurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years.↗
▶Ep 12 · 36:33
clinicalDr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal.↗
▶Ep 12 · 37:49
clinicalDr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up.↗
▶Ep 12 · 39:06
clinicalIn patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial.↗
▶Ep 12 · 40:04
quoteBecause 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.↗
▶Ep 12 · 40:04
opinionBecause brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients.↗
▶Ep 12 · 41:23
clinicalDr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands.↗
▶Ep 12 · 42:35
clinicalCandidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing.↗
▶Ep 12 · 43:13
clinicalThe reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest.↗
▶Ep 12 · 44:52
epidemiologicalThere is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history.↗
Robert's statements about Pectus Excavatum64 statements
quoteWhen 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.↗
▶Ep 20 · 1:33
clinicalCommon presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest.↗
▶Ep 20 · 2:55
clinicalBoth Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.↗
▶Ep 20 · 4:04
quoteA 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.↗
▶Ep 20 · 4:04
clinicalIn patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration.↗
▶Ep 20 · 4:29
clinicalIn pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath.↗
▶Ep 20 · 4:29
quoteWhat 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.↗
▶Ep 20 · 6:15
epidemiologicalIn a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.↗
▶Ep 20 · 6:15
quoteIn 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.↗
▶Ep 20 · 6:36
clinicalWhen both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon.↗
▶Ep 20 · 8:39
epidemiologicalIn the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain.↗
▶Ep 20 · 9:44
clinicalThe Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus.↗
▶Ep 20 · 10:09
clinicalThe Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant.↗
▶Ep 20 · 12:53
epidemiologicalMitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population.↗
▶Ep 20 · 13:37
epidemiologicalOn average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).↗
▶Ep 20 · 14:15
clinicalIn both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery.↗
▶Ep 20 · 14:37
clinicalRestrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.↗
▶Ep 20 · 15:05
clinicalPatients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.↗
▶Ep 20 · 15:11
guidelineDr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image.↗
▶Ep 20 · 15:35
clinicalAround the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct.↗
▶Ep 20 · 16:47
clinicalThe ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that.↗
▶Ep 20 · 17:02
clinicalHaving the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.↗
▶Ep 20 · 17:29
clinicalSome Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.↗
▶Ep 20 · 17:55
quoteIt'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.↗
▶Ep 20 · 18:32
quoteThe 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.↗
▶Ep 20 · 18:49
clinicalDr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback.↗
▶Ep 20 · 19:13
quoteWe'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.↗
▶Ep 20 · 19:39
clinicalDr. Kelly's center has not used epidurals for pectus excavatum surgery for several years.↗
▶Ep 20 · 19:47
clinicalPostoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery.↗
▶Ep 20 · 20:46
clinicalFor the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest.↗
▶Ep 20 · 21:37
clinicalThe Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance.↗
▶Ep 20 · 22:17
opinionTitanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate.↗
▶Ep 20 · 24:43
guidelineFor Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other.↗
▶Ep 20 · 24:43
quoteAt 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.↗
▶Ep 20 · 24:57
clinicalSternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify.↗
▶Ep 20 · 26:02
quoteThe, 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.↗
▶Ep 20 · 26:02
clinicalThe most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low.↗
▶Ep 20 · 26:43
clinicalTo prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib.↗
▶Ep 20 · 27:32
clinicalFor Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus.↗
▶Ep 20 · 27:39
clinicalIn post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient.↗
▶Ep 20 · 28:54
clinicalThe bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load.↗
▶Ep 20 · 28:54
quoteIf 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.↗
▶Ep 20 · 30:07
quoteIn 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.↗
▶Ep 20 · 30:07
clinicalIn growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar.↗
▶Ep 20 · 30:39
clinicalPatients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation.↗
▶Ep 20 · 31:17
clinicalThe Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities.↗
▶Ep 20 · 32:02
clinicalPostoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines.↗
▶Ep 20 · 33:03
epidemiologicalIn multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent.↗
▶Ep 20 · 33:14
epidemiologicalIn Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.↗
▶Ep 20 · 33:43
clinicalMost bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents.↗
▶Ep 20 · 34:13
epidemiologicalBar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy.↗
▶Ep 20 · 34:40
epidemiologicalWound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle.↗
▶Ep 20 · 35:07
epidemiologicalRecurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years.↗
▶Ep 20 · 36:33
clinicalDr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal.↗
▶Ep 20 · 37:19
clinicalThe vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients.↗
▶Ep 20 · 37:49
clinicalDr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up.↗
▶Ep 20 · 39:06
clinicalIn patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial.↗
▶Ep 20 · 40:04
opinionBecause brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients.↗
▶Ep 20 · 40:04
quoteBecause 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.↗
▶Ep 20 · 41:23
clinicalDr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands.↗
▶Ep 20 · 42:35
clinicalCandidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing.↗
▶Ep 20 · 43:13
clinicalThe reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest.↗
▶Ep 20 · 43:43
opinionThere is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.↗
▶Ep 20 · 44:52
epidemiologicalThere is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history.↗
Summaries Robert gave as host
· 5 summaries
Recaps of other experts' statements, not Robert's own clinical position.
Summaries Robert gave as host · Pectus Carinatum5 summaries
host summaryRobert Kelly summarizing a resource: The Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant.↗
▶Ep 12 · 17:29
host summaryRobert Kelly summarizing a resource: Some Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.↗
▶Ep 12 · 33:03
host summaryRobert Kelly summarizing a resource: In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent.↗
▶Ep 12 · 37:19
host summaryRobert Kelly summarizing a resource: The vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients.↗
▶Ep 12 · 43:43
host summaryRobert Kelly summarizing a resource: There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.↗
