Pectus Excavatum and Minimally Invasive
Surgery
Transcript:
Guest: Dr.
Andre Hebra - Surgery
Host: Dr.
Linda Austin – Psychiatry
Dr. Linda Austin:
I’m Dr. Linda Austin. I’m
interviewing Dr. Andre Hebra who is Professor of Pediatrics and Surgery and
Director of Pediatric Surgery here at the Medical University of South
Carolina. He is an internationally known
expert in the surgical repair of a condition called Pectus Excavatum. Dr. Hebra, could you explain what that is,
please?
Dr. Andre Hebra:
Pectus Excavatum is a congenital malformation of the chest in which the
sternum and part of the ribs in front of the chest are caved in, which gives a
variety of problems and it looks very bad.
Dr. Linda Austin:
I would imagine this is something that parents can see as soon as a baby
is born.
Dr. Andre Hebra:
That’s correct. The majority of
children that have Pectus Excavatum are diagnosed early in life. However, there are a number of kids in which
the condition is very mild when they’re infants and young babies, but as they
grow older, especially during puberty when they start growing fast, all of
sudden the chest will change and assume this very pronounced caved-in
appearance.
Dr. Linda Austin:
How common is this disorder? I’m
sure it’s a question of degree.
Dr. Andre Hebra:
Pectus is estimated to occur in about 1 in 500 to 1 in 1000 live births,
so it’s relatively common. In a
specialized center like ours, we see many adolescent children that have this
condition. In this day and age, it’s
something that needs to be looked at early on, as early as possible, to be
followed and evaluated by an expert in the field.
Dr. Linda Austin:
Is it genetic, for example, if a parent has one child with this, should
they be concerned that a second child born might also have it?
Dr. Andre Hebra:
Yes. Unfortunately, we do not
know what specific gene is involved.
But, without any doubt, there is a familial occurrence in more that 30
percent of the patients in which they will tell you that the father or
grandfather, or another sibling, had it.
It is also associated with connective tissue disorders, such as marfan
syndrome or poland
syndrome. It can be associated with
other less common anomalies, like mitral valve prolapse, and so forth. So, again, it is important that once you have
a child that has this condition, they should be evaluated by somebody that has
expertise in that area.
Dr. Linda Austin:
Now, you mentioned early on that not only is it a cosmetic problem that
the child might be self-conscious about, or an adult might be self-conscious
about, but it can cause health problems as well. What are those problems?
Dr. Andre Hebra:
By far, the number one reason patients are referred to us is because of
the appearance of the chest, because it’s so striking to see that sternum caved
in. A lot of adolescents have
psychological problems related to the appearance of the chest. But, the physical problems depend on the severity
of the Pectus. In very mild cases, there
will be minimal physiological impairment.
However, in more severe cases, what the caved-in sternum will do is
actually displace the heart to the left side of the chest and cause a
rotational anomaly of the heart.
Occasionally, this can cause mitral valve and tricuspid valve regurgitation
and it compresses on the lungs, decreasing, what we call, pulmonary
reserve. So, many young kids and
teenagers will tell you that they have shortness of breath. They’re unable to keep up with the
peers. They don’t perform as well in
sports. They, occasionally, will have
chest pain and discomfort. So, again,
these symptoms that we see will depend a little bit on the severity of the
deformity.
Dr. Linda Austin:
At what age do you begin to think about surgical repair of a pectus?
Dr. Andre Hebra:
It used to be, with open surgery, that these patients were treated when
they were older, as teenagers. But, with
the advent of the new treatment modalities, the so-called minimally invasive
repair, we now like to plan surgery between the ages of 8 and 12, at a much
younger age.
Dr. Linda Austin:
Do you prefer to do it in a younger child or an older child, if there’s
not a physical reason for making the repair?
Dr. Andre Hebra:
The big advantage of operating on younger children is that the operation
itself is a lot easier. The recovery
from surgery is much better and the cosmetic result and the repair you can
achieve is much better on somebody in which the rib and sternum are still
developing. If you intervene, say,
between 8 and 10 years of age, you will get a much better result than if you’re
operating at 15 years of age.
Dr. Linda Austin:
Now, your major contribution has been in the use of minimally invasive
techniques for doing this. Why is that
such an advantage?
Dr. Andre Hebra:
Well, several reasons. The open
surgery, also known as the ravage operation, is a very good surgery that was
developed and described in the 50s. But
it requires a large incision in the front of the chest, almost nipple to
nipple, and then you have to create muscle flaps and expose the ribcage. You actually remove the segment of the rib
and cartilage that is affected by this deformity and you have to fracture the
sternum in several places to make it flat again. And you have to sort of reconstruct the
anterior chest wall. It works, but it
leaves a scar. It takes several hours to
do. It’s a very painful operation. It’s associated with blood loss. You frequently need chest tubes, and so
forth. So, the popularity of the open
repair has never been very good.
About 10 years ago, a new technique came about, the
so-called minimally invasive repair.
It’s also referred to as the Nuss operation, because Dr. Nuss, in Virginia, was the
pioneer in developing this new concept.
He realized that you can correct this deformity by placing a stainless
steel bar behind the sternum using minimal access surgery. In other words, all you’d do is two small
incisions on the side of the chest and then place this bar that will push the
sternum and the rib cage out and remodel the ribcage and the sternum, similar
in fashion to braces for your teeth. The
difference is, with the operation, you achieve an immediate result of how the
chest will look.
A few years later, we actually modified the
operation a little bit to make it better and safer for the patients and achieve
better results by introducing thoracoscopy.
So now the operation is done with minimal access surgery and
thoracoscopy, which means there’s a small camera inside the chest that allows
us to look and see where the bar goes, place the bar very precisely where it
needs to be and secure the bar in such a way that it will not move. One of the problems with the early onset of
the operation is that the bar would actually move somewhat. Nowadays, with the modifications to the
technique that we developed, the bar is unlikely to move and the results are
much better.
Dr. Linda Austin:
Boy, that’s very exciting. Now,
does the bar stay there, then, for the rest of that person’s life, or is it
ever removed? What happens after the
surgery?
Dr. Andre Hebra:
Typically, the bar will stay for about two years. Anywhere between two and three years is the
recommended length of time for keeping the bar.
After that time, the ribcage will have remodeled itself so that the bar
can be removed and it [the ribcage] should stay the way it’s supposed to be.
Dr. Linda Austin:
What are some of the possible adverse consequences of this
procedure? When there are problems, what
kinds of problems might there be?
Dr. Andre Hebra:
The procedure itself has changed from what it used to be, about 10 years
ago, to what it is today. The early
reports and one of the large outcomes study, published by Dr. Nuss and I,
looked at the long-term outcomes of this procedure in the early series, before
the use of thoracoscopy and before the use of modern ways of stabilizing the
bar, and the complication rate was relatively high. It was about 10 to 20 percent, which is very
high for any type of surgery.
But, with the modifications that we introduced to this
technique and the new ways of securing the bar and the new ways of looking at
the bar placement, the complication rate has dropped to less than five
percent. So, nowadays, we consider the
operation relatively safe. Some years
ago, there was some reservation as to whether this operation would be
recommended for everybody. But,
nowadays, we can say that the advantages of this approach, leaving essentially
minimal scars on the side of the chest that are not even visible and correcting
this deformity is really the way to go.
Dr. Linda Austin:
So, what percentage, then, of patients who come to you end up getting
this technique, as opposed to the old open procedure?
Dr. Andre Hebra:
I can safely say that I haven’t done the old open approach in more than
six years.
Dr. Linda Austin:
That’s really something. Now, in
that less than five percent where there are complications, what are those sorts
of complications?
Dr. Andre Hebra:
The number one thing that we worry about is the risk of the bar displacing
or moving. What that means is, if the
patients are not totally compliant with our postoperative recommendations, if
they become too active too early, they run the risk that the bar is still not
quite fixed enough to where it needs to be and it may move up or down or
sideways. Usually, if there’s a little
movement of the bar, it’s not a big deal.
However, if the displacement is more than 90 degrees, it may require a
reoperation. So, we counsel our
patients. We work with them very closely
so that they know exactly what they can do and what they shouldn’t do. One example is they should avoid contact
sports. Contact sports are not allowed
during the time the bar is in place because of the risk of displacement.
Dr. Linda Austin:
Dr. Hebra, thanks so much for talking with us today.
Dr. Andre Hebra:
Thank you.
If you have any questions about the services
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Carolina or if you would like to schedule an
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