UCSF pediatric surgeon Sunghoon Kim, MD, presents an overview of pectus malformations, including images that illuminate how to distinguish types, ways to assess severity, and guidance on surgical and nonsurgical treatment options. Bonus: a new technique for controlling postop chest pain.
I'm going to talk about the chest wall malformation. Which could be divided into two broad categories. Pick this extra bottom and pick this carrying autumn pictures means chest X to bottom in sunken carrying out. Um The carry word karina is a latin word for the hell of the ship. The middle with that sticks out. That's where the work argue item is a subcategory your practice carrying out. Um That I'll also talk incidents of pictures. Excavatum is about one in 500. Usually boys are affected. There's up to 40% coincidence and family members. The ideology of the practice excavatum is not known. The usual symptoms include number one Two, chest pain, number three. Asthma like symptoms. A lot of patients do not have symptoms but as they get older they tend to get poor body image. And this is something that we should try to do something about. How do you measure the severity of the practice extra bottom. The main index that we use is called the heller index. And if you want to do a cT scan and do a measurement of the cross section of the chest and then you measure from the sternum to the spine. This ratio It's called the Hillary Index and typically the average index is about 2.2 but it becomes more than 3.25 is considered severe. Another way to measure the index is to use a chest X ray, which is a less radiation. So you do a P. A shot and then do a lateral and you can get the index number as well. What are some ways to evaluate the patients with very function test. You're looking to see if the patient has a restricted disease. You do an exercise testing. This is to look for decrease the title volume uh ratio be doing cardio cardio graham looking for right ventricular obstruction. You can also do an E. K. G. What are the treatments for practice? Excavatum. It could be divided into surgical and medical. Uh The old surgical method is sometimes called the ravaged procedure where you remove the pieces of cartilage next to the sternum by removing the college. You could uh we could the chest and then and then let them allow the chest to sing. Since the year 2000. We have mainly been doing the procedure using a nut procedure which doctor nurse came up came up around here in 2000. There's a method called magnet method that dr Harrison at UCSF has been trying to get FDA approve of past 10 years but it's not presently FDA approved. There's a procedure called picked us up which has been developed in spain but um the equipment for that is not developed within America medical treatment for the condition that you could use a vacuum device to raise the chest. Could also do an exercise. Yeah this is a this picture shows the nuss procedure where the metal bar is put into the chest and once the bar has been put in that is size to fit the patient and you flip the bar and the chest will be elevated. And and the metal bars malls a chest over a period of two years and after two years the mark. This is a picture of a doctor nuts in the middle. Um came up with the idea, Here's a picture of a patient that was 18 years old. He has a symmetric practices bottom and the right picture shows the results after the operation. This is a picture of a five year old girl who has a severe practice excavatum. The picture on the right shows the scar that is typically seen. And this is a picture of her two weeks later this is a picture of a girl with an asymmetric pick to sex the bottom we put in the bar too depressed the left chest and at the same time raised the right chest. And the picture on the right shows the results. This is a dictation with a very broad chest depression for this patient we put in to metal doors. Well there's some complications of the operation. The major, the most major life threatening complications cardiac proliferation. The second complication is the bar dislocation to prevent the cardiac corporation. This is the method that we use it all the T fastener future technique where we put in uh these strings and uh plates. We elevate the chest and once the chest is elevated we use cameras to dissect the tissue just turn and the heart and create the channel and once the channel is created, we passed the bar doing this method. We completely eliminate the chance of cardiac way to prevent the bar dislocation is the method that we uh it's shown here. Typically the stabilizer which is attached to the metal bar is located on the far lateral side. But hospital the way we do it just a stabilizer in front of the chest. So and then the bar is bent and using this um method, we absolutely basically have no dislocation involved. The post take post operation. Pain management for this procedure is it's difficult and in the past the patients had a lot of morbidity after the operation. Typically the patients used to get an epidural catheter and stayed in the hospital five or seven days and after about uh about a month the patients experience as some significant pain. But this has changed since two years ago. We came up with a method of using cryo analgesia uh in conjunction with the next procedure and using this man did Essentially, patients could go home next day and about after about a week. The pain level is typically 123. The method is to freeze the nerve and of the intercostal nerves on both sides so that the front of the chest becomes numb for two months and after two months the sensation comes back when all the pain is gone. This is a picture of the intercostal nerve Where the -60 cold is applied. The Exxon's are frozen And they do not work for two months. So the front a chance becomes now Over the period of two months the Exxon's regenerate. And at the end of the two months the sensation comes back when all the pain on the front of the chest is gone. What are some medical therapy for Hector's excavatum? This is a picture of a device called vacuum bell, which was invented in Germany. This is applied to the chest And by pumping out the air, you elevate the chest. You wear the device about 24 hours a day. And this could be obtained by um by purchasing the device from Germany. Uh This device on the right side is a our own device that we plan to manufacture perhaps starting next year and it's called the practice back. And once we get this device, american patients will not have to resort to right into the german company to obtain this device. Another way to treat the picture sex commodities to do exercise. And here's a picture of a boy after a fairly aggressive physical therapy or physical exercises change the shape the chest and the best exercise in my opinion to improve the chest is to do push ups. I'm gonna talk about pictures. Karen item now and picked us. Karen item is also Almost common is actually has picked this extra bottom. It can be divided into typical versus a typical 90% of time. It's either symmetric or asymmetric Incidents. That is again about one in 500 is more common in mail. There is some familiar incidents. The ideology of the practice carried out in Autumn is known. It is due to the cartilage is being overgrown is too long and there's not enough space. Therefore they produce uh onto the front. Here's a picture of a symmetric practice. Karen Autumn. It's a picture of an asymmetric on the right side. And this is a picture of a patient with something called practice articulate. Um It's got other names to it also known as career, you know Silverman syndrome On his type two carried out him these patients and take a picture of their sternum. The sternum is one piece of bone is fused uh compared to a normal sterner where you have the manubrium and the sternal body which has separated. So if you were to do a plain X ray, you could confirm the diagnosis. But sometimes this could be confused with practice excavatum. So here's a picture of the patient on the left with the argue Autumn and the patient on the right way has an extra bottom. So if you look at the patient on the RQ Autumn, the bump is up up here where the sternum and the body of the stern of meats and then they have a depression here. Air to an extra volume patient. Usually the depression is below the nipple mark. If you see if you see a patient with this pick this arche. Autumn, you should do a careful uh cardiac examination because a substantial number of these patients may have cardiac anomaly. How do you treat texas Karen Autumn? You have a surgical method also called ravaged procedure. Uh ravage procedure is similar to the surgical operation that I mentioned to you the pictures at the bottom and that he removed the pieces of cartilage next to the sternum by shortening the length of the cartilage. You could flatten the chest. There are other methods of operation. Uh You could divide it into extra Jurassic intra thoracic method and one of the we doctor do and I came up with one of the intra thoracic methods. But 95% of the patients could be treated using nonsurgical method namely using braces. The idea behind surgical method is to remove the cartilage to shorten the length. There's a picture, here's some pictures of pre and post op patient pictures. This patient is not that bad, but this patient you could see, it's pretty severe. Another method of treating uh the condition using a surgical method is using a external compression and this uh this idea of using the sternal bar was developed by dr abramson and uh you have to make an incision and then you place a metal bar which will compress the chest. And then you lock the metal bar onto the side. Here's a picture of for now, the most common way to treat the practice carrying out. Um And uh it is best to try to treat the patient as early as possible because when the chest is uh not stiff, the force that is needed to compress the chest and correct the chest as much as lower and shorter. There's a picture of a brace that was invented by dr Haji. Here's a typical another brace that's made by hangers. This is a picture of a race that's made by UCSF Orthotic Service. This is a custom made brace. This place is called the balloon brace. So there are multiple different styles of braces that patients have uh that they could choose to use. Here's a picture of a boy who has a pressure to correct about 2.5 it's very soft chest and it only took three months to correct the chest. There's a boy who has the pressure of 2 to 2.5 to five took about six months. And here's a picture of a teenager has a pressure of about five. It took about a year. So um earlier you treat the patients that carry or not in the better. So it's best to refer these patients as soon as possible. So they could uh so a lot of patients ask which braces best and the breaks that is best is the one that patient wears the longest, meaning that They can wear 16 hours a day compared to 12 hours a day. Any brace that patient wears that's longer than 1616 hours will be better than 12 hour years. Mm. That concludes the talk.