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.
s I'm going to talk about the chest wall malformation, which could be divided into two broad categories. Picked extra bottom and picked us carrying autumn pictures. Miss Chest Exco Bottom in sunken Karen Autumn The Carry The word Karina is a Latin word for the hell of the ship. The middle with that sticks out. That's where the work argue. Adam is a subcategory of practice carrying out that I'll also talk incidents of practice. Exco bottom is about one in 500. Usually boys are affected. There's up to 40% coincidence and family members. The ideology of the practice Extra bottom is not known. The usual symptoms include number one threat chest pain number three, asthma like symptoms. Ah, 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 Thio do something about Have you measured 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 C T scan 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 indexes about 2.2 comments more than 3.25 It is considered severe. Another way to measure the index is to use a chest X ray, which is the less radiation. So you do a P A shot and then do a lateral, and you could get the index number as well. What are the some ways to evaluate the patients with them? Very function test. You're looking thio disease. You do an exercise. Testing. This is to look for decrease the title volume, uh, ratio. Good doing cardio cardio Graham looking for right, right ventricular obstruction. You could also do an e k G. What are the treatments for practice? Excavate. Um, it could be divided into surgical medical the old surgical method sometimes called the ravage procedure, where you remove the pieces of cartilage next to the sternum. By removing the college, you could, uh, the chest and and and let the allow the chest the same. Since the year 2000, we have mainly been doing the procedure using the notes procedure, which ducting us came up with, came up around here. 2000. There is a method called magnet method that Dr Harrison at UCSF has been trying to get FDA approved for 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 development in America. Medical treatment for the condition that you could use a vacuum device Thio raise the chest could also do exercise. This is a This picture shows the Nuss procedure where the metal bar is put into the chest and the ones that Boris and put in that is size to fit the patient and you flip the bar and the chest will be elevated. And okay, the metal bars malls a chest over a period of two years, and after two years, the the this is a picture of a doctor. Nuts in the middle came up with the idea is a picture of a patient that was 18 years old. He has a symmetric bottom, and the right picture shows the result after the operation. This is a picture of a five year old girl who has a severe practice extra volume 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 a symmetric practice. Escobar. Um, we put in the bar Thio depressed the left chest and at the same time raised the right chest. And the picture on the right shows the result. This is a pick patient with a very broad chest. Depression for this patient were put in to metal bars. 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 preparation. This is the method that we use it all the T faster suitor technique where we put in, uh, these strings and, uh, way elevate the chest. And once the chest is elevated, we use cameras to dissect the tissue this term 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 way it's showing here. Typically, the stabilizer, which is attached to the metal bar is located on the far lateral side, but our hospital, the way we do it, just stabilizer in front of the chest. So and then the bar is spent and using this, um, Method way absolutely, basically had no dislocation of all the post take post operation pain management for this procedure is it is 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 5 to 7 days, and after about a month, the patients experienced some significant pain. This has changed since two years ago. Way came up with a method of using cryo analgesia on in conjunction with the North procedure and using this man did. Essentially, patients could go home next day and above. After about a week, the pain level is typically 123 The method is to freeze the nerve 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 eyes gone. This is a picture of the intercostal nerve where the minus 60 cold is applied, the excise are frozen and they do not work for two months. So the front of chance becomes now, over the period of too much the Exxon's regenerate. And at the end of the two mud, the sensation comes back when all the pain on the funded chats is gone. What are some medical therapy for Hector's extra bottom? 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 1 to 4 hours a day, and this could be obtained by um by purchasing the device from Germany. Things device on the right side is a our own device that we plan thio manufacturer, perhaps starting next year, and it's called the practice back. And once we get this device, American patients will not have Thio Resort Teoh right into the German company to obtain this device another way, Thio treat the practice X commodities to do exercise, and here's a picture of ah boy. After a fairly aggressive physical therapy or physical exercises, change the ship the chest. And the best exercise, in my opinion, to improve the chest is to do push ups. I'm gonna talk about Peck. Does Karen Autumn now and picked us? Karen Autumn is also what's 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 it's a metric incidents that is again. About one in 500 is more common in mail. Uh, there is familiar incidents. The ideology of the practice carry not not, um, is known. It is due to the colleges. Being overgrown is too long, and there's not enough space. Therefore, you produce onto the front. Here's a picture of a symmetric practice. Karen Autumn. It's a picture of a asymmetric on the right side, and this is a picture of a patient with something called practice rq Lottum. It's got other names, too, it also known as career. You know, Supplements syndrome. One is type two carried out, um, these patients and if you take a picture of their sternum, the sternum is one piece of bonus fused, uh, compared to a normal starting where you have the manubrium and the sternal body, which has separated. So if you want to do a plain X ray, you could confirm the diagnosis, but sometimes it this could be confused with practice. Extra bottom. So here's a picture of a patient on the left with the argue autumn, and the patient on the right way has a 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 sternum 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 picture Starkey Autumn, you should do a careful cardiac examination because a substantial number of these patients may have cardiac anomaly. How do you treat practice? Karen. Autumn. You have a surgical method, also called ravaged procedure. Uh, ravaged procedure is similar to the surgical operation that I mentioned of Victor's extra bottom in 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 harassing and characteristic method, and one of the we doctor do and I came up with one of the intra thoracic method. But 95% of the patients could be treated using nonsurgical method may be using braces. The idea behind surgical method is to remove the college to shorten the college length. There's a picture. Here's some pictures of pre and post op patient pictures. Thats patients is it's not that bad. But this patient you could see is pretty severe. Another method of treating the condition using a surgical method is, uh, using a external compression. And this, uh, this idea of using the stern of our was developed by Dr Abramson and this 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 site. Here's a picture of for now, the most common way to treat the practice carrying out Um, and, uh, it is best thio to treat the patient as early as possible because when the chest is, uh, not stiff the force that is needed thio compress the chest and correct the chest as much as lower and shorter. There is a picture of a brace that was invented by Dr Hodgins. Here's a typical, um, other Braves that's made by hangers. This is a picture of a race that's made by UCSF Orthotic Service. This is a custom made race. This breaks is called the balloon brace. So there are multiple different styles of braces that patients have that they could choose to use. Here's a picture of a boy who has a pressure to correct. About 2.5 is very soft chest, and it only took three months to correct the chest. There's a boy who has the pressure of 22.5 to 5, took about six months, and here's a picture of a teenager who has a pressure of about five. It took about a year so earlier. You treat the patients with carrier not in the better. So it's best Thio. Refer these patients a soon as possible, so they could, uh so a lot of patients ask which brains is best, and the brace that is best is the one that patient wears the longest, meaning that, uh, they could wear 16 hours a day, compared to 12 hours a day. Any brace that patient wears that's longer than 6 16 hours will be better than 12 hour use that concludes the talk.