What is pectus excavatum?
Pectus excavatum is a condition characterized by abnormal growth of the chest where several ribs and the sternum are caved in, producing a concave anterior chest wall. This condition is also called as “funnel chest” or sunken chest”. It is a congenital condition, presented in birth, and later in life may be developed in different directions (it may get lenient or serious). It is mainly followed by pectus carinatum.
It is estimated that there is one case with pectus excavatum in every 300-400 births.
What is the cause of pectus excavatum?
The exact cause of pectus excavatum is not known yet. According to the latest researches, specialist believes that it is caused by abnormal and not able to be controlled growth of the connective tissue that is connecting the ribs to the breastbone. Also, it is believed that is inherited conditions because there are cases when this deformity is run in the family from generation to generation.
What are the symptoms of pectus excavatum?
For the majority of people, the only sign of pectus excavatum is the concavity in their chest. In the beginning, the indentation may be small, but later in the early adolescence it may get bigger and cause more serious complications.
There are cases that are showing other symptoms, along with the indentation of the chest. Some people are experiencing:
- Chest pain
- Fasten heart biting
- Respiratory infections
- Shortness of breath
Are there any risk factors that are increasing the chance to have pectus excavatum?
According to the studies, pectus excavatum is a more common condition in boys than in girls. Also, this condition occurs more in people that are having:
- Marfan syndrome
- Turner syndrome
- Ehlers-Danlos syndrome
- Noonan syndrome
- Osteogenesis imperfect
What are the complications caused by pectus excavatum?
The main complications are related to the heart and lungs or with the person’s self-esteem.
The abnormal growth and the concavity of the chest may compress the heart and the lungs, or change the position of the heart to the other side. There may be less room for the lung to expand while breathing,
Self-esteem related problems are very often, especially between the kids that are having this condition. They are frustrated by their look and appearance, so they lack themselves from many social activities, especially the activities such as swimming.
How can be this deformity diagnosed?
Setting the diagnose pectus excavatum is very simple. The diagnosis is done by a simple physical examination of the chest. After that, the doctor may tell you to do several other tests in order to see if there are any additional complications with your heart and lungs. The additional tests that are done are:
- Physical (stress) test – shows the function of the heart and the lungs while exercising, Usual it is done on a bike
- Pulmonary function test – This test measure the amount the air in the lungs, and how fast the lungs can be emptied.
- CT (computed tomography) on the chest – the CT scan produces cross-sectional images of the internal structure of the body, shown in different angles. Shows whether the organs in the thorax are compressed.
- Chest X-ray – With this ray doctors are able to see if the heart is placed on the left side of the chest. Also, visualization of the dip is possible with the chest X-ray.
- Laboratory work (blood test) – a Blood sample is taken in order to check the blood status for a diagnose.
- Test for chromosomes and enzyme status
- Metabolic studies
- EKG (Electrocardiogram) – With the help of EKG, doctors are able to see whether the rhythm of the heart is normal or irregular, and investigate the electric signals of the heartbeat.
- Echocardiogram – It is a sonogram of the heart. Real images show how the heart is working, how well the heart is and the proper working of the valves. Transmitting sound waves are producing the images.
Who Should Consider Treatment?
You can’t prevent pectus excavatum, but you may treat it. In the most of the cases, pectus excavatum is visible by the person’s physical appearance. But, also there are some symptoms that may indicate pectus excavatum, like:
- Shortness of breath
- Pain in the chest region
- Irregular heartbeat
- Decreased stamina
Also, another common symptom is the embarrassment from the physical appearance. People are having self-esteem problems that may cause depression as well. Help from a psychologist or psychiatrist Is essential.
What are the possible treatments for pectus excavatum?
For the most of the patients that don’t have symptoms, treatment is not needed. After showing some symptoms, they may consider getting a treatment.
There are some options for treatment two of them surgery ( The Nuss Procedure, Modified Ravitch Technique) other conservative treatment ( vacuum bell treatment).
Upon the young children, physical therapy is the most commonly considered type of treatment. During the young ages, physical therapy is considered because it may still reverse some of the deformity of the chest wall.
For the people that are having more than eighteen years, surgery may be considered, especially if the deformity is causing problems to the heart and to the lungs. The statistic data were taken in the last years show that the surgery can improve the function of the heart, of the blood vessels and of the lungs significantly.
The most important goal of the surgery is to improve the chest deformity, and with that to improve the patient’s health condition.
There are two types of surgeries that are commonly used as a treatment. The main difference between them is whether the cartilage is removed or nor, and the size of the incisions.
The Nuss Procedure:
The Nuss Procedure is mainly for the young children, and not advised for the older people. Surgeons use VATS – video-assisted thoracoscopic surgery to repair the pectus excavatum.
It is mostly recommended for children because they have a soft chest. The anterior chest wall is quite malleable. In this technique, a stainless steel bar (known as Lorenz Pectus Bar) is placed under the sternum through a previous small incision made in order to correct the condition known as funnel chest. This method includes minimally invasive incisions, and at the same time, it is helped by thoracoscope for guidance.
The length of the bar is determined by measuring the line that connects the two midaxillary regions. From the obtained length, 1 cm is a substrate and that is how the perfect length of the stainless steel bar is determined. Typically, 1 hour before the surgery, a first generation cephalosporine antibiotic – cefazolin is given to the patient.
Also, before the surgery, generally endotracheal anesthesia combined with a thoracic epidural is given. The epidural catheter is left up to 3 days after the surgery. Although it is a minimally invasive, patients will experience postoperative pain and discomfort. This is due to the manding of the cartilages with the sternum, made my force.
The bar is not visible from the outside and stays in the same place approximately for two years. After that, when it is no longer needed, the bar is removed.
Modified Ravitch Technique:
The Modified Ravitch technique is done by a long incision across the chest. The excessed cartilage is cut out, then the rib bones are repositioned and a wedge bone is implanted.
The patient is positioned with this birth hands abducted to the shoulders in order to provide a better access to the lateral walls of the thorax. The left and the right intercostal spaces are marked, and it shows the place where the bar will be inserted. As well, the points of the pectus ridge are marked that are showing the horizontal plane from the deepest point of the pectus to the lateral chest wall incisions.
The length of the bar is measured as a line that connects both mid-axillary points. It is bent from the center to each end. The shape of the bar is customized to fit every patient’s chest wall, so the curvature depends on the patient’s chest.
A 2 cm transverse surgical cut on the skin is made on the midaxillary line, on the right, and on the left side. With this, a skin tunnel is obtained anteriorly from the incisions to the top of the pectus ridge. This will allow the pectus bar to hug the wall of the thorax posteriorly.
In this procedure, a thoracoscope is inserted, 1 or 2 intercostal spaces below the space where the bar was inserted. With this, a great visualization is provided. A vascular clamp is inserted through the right intercostal space.
The sternum is lifted by force as the instrument is passing to the contralateral side. During this whole procedure, the heart is monitored all the time in order to be sure that the instrument is not anywhere near the heart.
When the instrument is inserted on the contralateral side, the tip is pushed through the intercostal space and got out through the left skin incision.
If the Lorenz bar is inserted, then no further dilating will be needed. If the Crawford clamp is inserted, then the tunnel space will be enlarged. They come in different sizes: shorter for kids and larger for adults.
After the placement of the bar, the stability of the bar is crucial. A stabilizer is put, in order to prevent the rotation of the bar in the chest, and it joins the bar and the chest muscles. One stabilizer on each side is required usually for younger kids, and more stabilizers are put to the adults.
The epidural catheter is removed on the third day after the operation.
The patient is extubated deeply in order to prevent any movement that may move and relocate the bar. The patient will experience the strongest pain the first three days, and after that, the intensity of the pain will be minimized. For this purpose, the patient is under sedatives in the first three days. Therapy is individual for every patient, depending on his response to the pain. Extra help is required for the patient in the first three days when getting up from the bed and for eating.
The average hospital stay lasts up to 7 days, and the patient is released from the hospital when he/she it will be able to walk on its own.
The bar stays for two years maximum, and then it is removed in a procedure under anesthesia.
The Modified Ravitch technique is requiring much shorter operating time, less blood loss and a minimal scar on the anterior chest. The stability of the chest wall is not compromised. Also, with this procedure, the “thoracic construction” complication does not seem to occur. This complication is characterized by affected bone growth center and restriction of the chest wall is occurring that leads to a marked limitation of ventilatory function. The expiratory volume is decreased and that patient cannot do running physical activities. With MIRPE, such a complication is not a problem. With this procedure, the pulmonary function is normal and improved.
The ideal age for this surgery is between 5-12 years, while the chest wall is still growing. But, this technique was used in the adult patients with huge success as well, which means that is not per limited age only.
Conservative Treatment With Vacuum Bell:
Vacuum bell is a conservative, special treatment for correcting pectus excavatum. It was discovered 10 years ago, as an alternative option to the surgical treatment. The vacuum bell, with the help of hand pump, creates a vacuum at the anterior chest wall. There are different sizes of vacuum bell available, depending on the patient’s age and size. This device can be used at home, twice a week and several hours per day. When the vacuum is created, the sternum is lifted together with the ribs and stays in that position for some time. The long-lasting results from this treatment are showing remarkable effects and success. For now, there aren’t any side effects noticed. You can buy vacuum bell trough our website.
What Are the Benefits Of Surgery:
Most of the people that have decided to undergo surgery are happy and satisfied with the obtained result. The best results are gained if the surgery is made during the young ages of the patient when the bones and the cartilages are still growing and developing, but this doesn’t mean that the adults don’t have benefits from this surgery too.
The primary goal of the surgery is to reduce the compression of the heart and lungs. It is expected that if the patient is going to get appropriate recovery, the endurance of the patient and the physical activity and exercise tolerance will be improved.
Are there any possible risks from the surgery and if there are, what are they?
Like any other procedure, this procedure also is presenting certain risks. Both procedures are safe and done with advanced instruments, still, there may be several complications.
Possible complications that may occur during the pectus excavatum surgery are the followings:
- Bar displacement and erosion through the skin
- Pleural effusion
- Pectus excavatum recurrence
Before doing the surgery, a consultation with a cardiologist and pulmonologist are required. They are really important for the procedure, as well as if the insurance companies don’t want to cover the operation.
According to recent studies, mainly the complications are more common for the younger patients, especially the bar displacement. Because of this, a third fixation technique was obtained in order to provide additional support. The results are good and improved so that the MIRPE operation is done successfully in a much older patient without complications.
Consultation with a physical therapist after the operation is important for better recovery from the surgery. The physical therapist is giving special instructions for exercises that are mandatory during the recovery period. Physical therapy should last around two months when the patient is no longer experiencing any kind of pain and it is prepared to start with the normal everyday routines.
Is there any special diet required?:
Because of the narcotics and all the sedatives that are used during the whole procedure, constipation is a common effect. Due to this, a high-fiber diet and laxatives are recommended for a few days after the surgery. Some other dietary restrictions are not required.
Activities after the surgery:
Patients must avoid banding of the hip for the first month. Also, lifting heavy things is not permitted in the first month. In the first three months, except the exercises and the activities that are recommended by the doctor, other sports are strongly forbidden. After three months, they may start doing some sports, but to take care not to get hurt. Patients will be able to do normal activities after the removal of the bar, which is usually after two to three years after the repair of the pectus excavatum.