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Funnel chest (pectus excavatum)
Minimally invasive surgery for pectus excavatum
Pectus excavatum minimally invasive surgery currently comes in two varieties. The first resembles a variation of the traditional Nuss procedure, which involves making a small incision under the patient's armpit and inserting a pre-shaped trapezoidal steel plate through this small hole to the back of the depressed breastbone. The steel plate is then flipped to push out the depression. Because it requires only a one to two centimeter incision on the patient, it is considered much less invasive compared to the traditional Nuss procedure which requires two incisions. There is also another type of minimally invasive surgery which involves bilateral incisions but does not require flipping the steel plate, thus avoiding damage associated with flipping and muscle disruption between the ribs. This is also considered a current minimally invasive surgical technique. Additionally, there is the recent Wang procedure, which is also minimally invasive, requiring only one incision and not necessitating access behind the breastbone. However, it is generally suitable only for younger patients with softer breastbones. For older adults, the Wang procedure might not be appropriate and further observation is required.
Pectus Excavatum should visit which department?
Pectus excavatum should be consulted with which department? Pectus excavatum is a type of congenital chest wall deformity, accounting for over 90% of all anterior chest wall deformities, and is primarily characterized by a depression in the middle of the chest wall that sinks inward and backward. As it is a congenital deformity, it can be noticed in children soon after birth, around the age of three to five, especially during bathing. This deformity may worsen with the patient's age, so you might consider consulting the pediatric health department. However, this indentation usually intensifies during puberty, and the pediatric health department primarily provides consultation services. If you seek a comprehensive assessment and treatment for pectus excavatum, you should consult the thoracic surgery department, which offers a range of treatments from surgical to non-surgical methods. Therefore, it is recommended to first consult the thoracic surgery department, followed by the pediatric health department.
Pectus excavatum causes
The etiology of pectus excavatum is not fully clear yet, but it has been found that the incidence of pectus excavatum greatly increases among patients with connective tissue diseases, possibly related to the disruption of the balance between growth genes and inhibitory genes affecting the cartilage on both sides of pectus excavatum. Moreover, it is also found that the complication of pectus excavatum significantly increases among patients with Marfan syndrome (also a type of connective tissue disease) and Noonan syndrome. In children with congenital airway stenosis and bronchopulmonary dysplasia, the incidence of pectus excavatum also significantly increases. This suggests that the causes of pectus excavatum are directly or indirectly related to genetics and heredity, and regardless, the causes of pectus excavatum, both acquired and congenital, are directly related to genes and heredity.
Best age for pectus excavatum surgery
The best age for funnel chest surgery, according to the latest and most authoritative ninth edition of the surgical textbook, is between three and five years old. Historically, there has been controversy over the best age for funnel chest surgery, with some pediatricians previously believing it should wait until adolescence. However, it has been found that by the age of five, children start to become more aware and might realize their chest shape differs from others, potentially leading to feelings of inferiority and reluctance to make friends. Thus, performing the surgery before the age of five—before the child is fully aware of their deformity—might actually be preferable, as it could minimize psychological and physiological impacts. Of course, there is also a viewpoint supporting surgery before the age of three, but the younger the child, the softer the chest bone, which sometimes allows for other potential corrective methods.
Is pectus excavatum hereditary?
Is pectus excavatum hereditary? According to modern genetic medicine, actually, about 80% of diseases are related to genetics to some extent, and pectus excavatum is no exception. Normally, pectus excavatum occurs in about one in 400 to 1000 people, with a higher prevalence in males. Research has also found that pectus excavatum is often seen in several genetic disorders, including Noonan syndrome, Turner syndrome, and Marfan syndrome. This indicates that it shares certain genes with these genetic disorders, such as the fibrillin-1 gene and others in the RAS/MAPK pathway. These genetic correlations may not always be evident, for example, the parents may not have pectus excavatum themselves. However, when parents with these recessive genes reproduce, their combination might result in pectus excavatum in their child. The development of pectus excavatum might be related to abnormal asymmetrical development of the cartilage. Thus, there is indeed a certain correlation between pectus excavatum and genetic factors.
How to exercise to correct pectus excavatum
Pectus excavatum refers to the inward and backward indentation of the sternum, a deformity that can compress the patient's heart and lungs. To exercise for pectus excavatum, patients are advised to practice deep breathing exercises to enhance lung function, as well as engage in appropriate running and routine physical activities to strengthen heart function. However, in cases of severe pectus excavatum which severely compresses the heart, even pushing it entirely to the left side, patients may not be able to tolerate running and other intense activities. Therefore, it is quite difficult to completely correct pectus excavatum through exercise alone. Some parents might think that doing push-ups can correct pectus excavatum, but push-ups make the pectoral muscles on both sides stronger, and since these muscles pull outward, the force is not directed in the same way as the inward and backward indentation of pectus excavatum. Furthermore, continuously training the pectoral muscles causes them to develop, and the resultant thickening of the muscles on both sides can exacerbate the inward and backward indentation of the sternum in the middle. Thus, after appropriate cardiovascular and pulmonary exercises, those with severe pectus excavatum should still consult a doctor for active advice and consider surgical treatment options.
Postoperative complications of pectus excavatum surgery
In theory, if the pectus excavatum surgery is successful, there won't be many long-term complications. However, if we have to discuss possible complications or side effects, they can be categorized as either short-term or long-term. For instance, pectus excavatum itself involves the inward and backward indentation of the sternum, which compresses the patient's heart and lungs. The surgery corrects this by pushing or suspending the indented sternum forward. Due to the alteration in the shape and appearance of the bones, the patient may experience some pain post-surgery, but this pain is bearable and usually subsides within three to five days. Particularly in younger children, who have softer bones, normal activities can often be resumed in just a day or two. However, as age increases and bones become harder, patients may feel pain for about three to five days to a week post-surgery, but typically return to normal after a week. Additionally, there might be complications such as pneumothorax, pleural effusion, or even severe cardiac damage. However, these are generally problems that arise from unsuccessful operations or issues that can be resolved in the short term. Therefore, in the long term or over an extended period, there are generally no lasting side effects from pectus excavatum surgery. If there has to be mention of any, it would be the surgical scars left under the armpits, typically one to two scars each measuring 1 to 2 centimeters.
Causes of Pectus Excavatum
Although current medicine has developed to the molecular and genetic levels, the true causes of many modern diseases are still not completely clear, which includes pectus excavatum. There have been medical cases indicating that scientists have never ceased to explore the causes of pectus excavatum. It was once believed by early medical scientists that pectus excavatum might be caused by the inward and backward pulling of the sternum by the diaphragm. Therefore, for a period, the treatment for pectus excavatum involved releasing adhesions of the diaphragm, but this method was later found to be ineffective for children and was abandoned. Subsequently, it was discovered that pectus excavatum is somewhat related to the genetics of many families, such as those with Marfan syndrome (an autosomal dominant hereditary connective tissue disorder) and Noonan syndrome (a genetic disorder caused by mutations). However, no definitive pathogenic genes have been identified in families with sporadic cases of pectus excavatum. In summary, pectus excavatum is currently believed to be possibly caused by factors such as the development of rib cartilage on both sides, genetics, and other acquired conditions, like underdeveloped laryngeal cartilage or post-surgical factors from congenital diaphragmatic hernia repair. Overall, the causes of pectus excavatum are still actively being explored by medical scientists.
Difference between funnel chest and pigeon chest
Pectus excavatum and pectus carinatum are both types of deformities of the anterior chest wall, with pectus excavatum being the most common deformity, accounting for 90% of all anterior chest wall deformities; the incidence of pectus carinatum is only one-fifth to one-sixth of that of pectus excavatum. The shapes of pectus excavatum and pectus carinatum are also completely different. Pectus excavatum appears as if a funnel were placed on the chest, with the funnel receding backward and downward. Therefore, patients with pectus excavatum, when lying down, can observe a depression in the front of their chest, which is even capable of holding a cup of water placed within this funnel-like depression. On the other hand, the deformity in pectus carinatum protrudes forward. One caves inward while the other protrudes forward, thus these two shapes are completely opposite.