Latest / Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner / Cranes and Cryo, Braces and Blocks: Pectus Care in 2026

Transcript

Cranes and Cryo, Braces and Blocks: Pectus Care in 2026 · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

0:00
I'm Holly Wayment, and this is Pediatrics Now, cases,
0:04
updates, and discussions for the busy pediatric practitioner,
0:07
brought to you by the Department of Pediatrics at UT Health San Antonio and
0:11
University Health's new Women's and Children's Hospital.
0:15
I'm so thrilled because joining me here in the podcast studio is Dr.
0:20
Ian Mitchell, Surgeon-in-Chief at University Hospital.
0:25
Dr. Mitchell, thank you for being here in the podcast studio.
0:28
My pleasure. It's great to be here.
0:30
Today, we're talking about chest wall abnormalities.
0:33
Ian, can you walk us through the current understanding of pectus excavatum and pectus carinatum?
0:39
How do these deformities typically present, and at what ages do we start to see them clinically?
0:45
So, these are actually quite common deformities, so pectus excavatum and pectus carinatum.
0:50
If you take all chest wall deformities, people are going to call it about 1
0:54
percent of the population.
0:56
Which is just interesting because
0:57
then you read the numbers and they talk about 1 in 250 to 1 in 300.
1:02
So it's somewhere between 1 in 100 to 1 in 1,000. But it is something that if
1:07
you just run the numbers, most pediatricians, certainly any pediatrician who's
1:11
been in practice for more than a couple of years, will see patients with a chest wall abnormality.
1:15
And there are some very rare ones like pectus arcuatum and some other even rarer
1:22
things. but excavatum is about 95%, 90%, and carinatum about 10%.
1:28
And they kind of mean what they say.
1:30
Excavatum is a cave chest. It's when your sternum sticks in a little more than
1:35
it should, and carinatum when your sternum sticks out.
1:38
And the most common location for that, either depression or elevation,
1:42
is really at the bottom of the sternum near the xiphoid process.
1:45
So it's really common that their upper chest is relatively normal,
1:48
but their lower chest sticks in while their ribs flare out in excavatum or in
1:54
carinatum where everything just kind of sticks out a little bit more than it should.
1:58
Clinically, we start to see them really at any age.
2:01
If you ask a lot of parents, they'll ask how long a typical,
2:05
either one actually, how long has their chest been like that?
2:08
And the parents, and for, I usually see them when they're teenagers is the vast
2:12
majority, but a lot will say, you know, it's kind of been like that for a long time,
2:18
like since they were five or six and maybe it was a little bit indented and
2:22
no one thought much about it, or a pediatrician noted it and just said,
2:25
you know, we'll see what happens as they grow.
2:27
And the most common time we present is when they're about 11 through 15,
2:32
they get that growth spurt as teenagers, and then they just become more pronounced
2:37
either which way that they go.
2:38
I have seen children as young as three years old with a significant pectus excavatum,
2:43
And there are reports of children being repaired that young,
2:47
but we really don't emphasize that or recommend that in a routine fashion.
2:53
What screening pearls would you share with pediatricians who might notice subtle
2:57
asymmetry in a child's chest during a well check?
3:01
A lot of times, if you see small asymmetries, first of all, I'm always happy to see them.
3:06
We're always happy to see the patient and speak with the family.
3:09
But a lot of times, if you notice it, it's really that longitudinal follow-up.
3:14
So you may see it one year, and then the next year, it may still be kind of
3:19
not sure, or it may be pronounced. And no pectus deformity caused a significant
3:25
problem going from one year to the next.
3:27
And so I think that's something else where I would recommend to the pediatricians
3:31
that the parents may start asking Dr. Chad GPT or Dr.
3:35
Claude what to do, but really reassurance at this point and knowing that many
3:41
of these either are so minor as to never cause a problem or are modest enough
3:46
that they may need something, but they're not going to need something from years from now.
3:50
And I think as we get into the physiology a little bit, people will see that
3:54
there's no rush to do anything.
3:56
I remember in childhood, a classmate had, you could tell like his chest was
4:01
really indented, but it was, I mean,
4:05
when is it, is it just if it's bothering the child and the family or how do
4:10
you decide if something needs to be done?
4:12
Well, now we can have a five-day conference reviewing the literature on that.
4:17
And just like you, I laugh. I had a friend who never got his repaired,
4:21
and in college, he actually used to have girls shoot jello shots out of his pectus exceded.
4:25
There is still some utility of the unrepaired pectus, but it's actually really controversial.
4:32
The things that we do know is that if you repair a pectus excavatum,
4:37
you will see an improvement in exercise physiology based on numbers.
4:42
Their pulmonary function tests will get better.
4:45
If you did a cardiac MRI, which I don't recommend, but if you did that,
4:49
we actually know that those functions get better.
4:51
What is really, really hard and has not to my convincing been proven is that that actually matters.
4:59
People will talk about how, well, the kid really didn't do that much and was
5:03
sort of a slouchy teenager who played video games. And then we fixed them.
5:06
And now they're doing sports and they're hitting the gym and they're doing all these things.
5:10
But is that because they got their chest fixed, now they like the way they look
5:14
in the mirror and they start playing sports and doing those things.
5:18
And I think that that's really kind of the take home message is,
5:21
is it a cosmetic operation?
5:23
And the answer is it improves someone's cosmesis significantly.
5:28
And there is definitely psychological benefit in patients who have a psychological
5:33
problem related to their pectus.
5:35
Does it improve their exercise physiology? Yes.
5:40
However, did that improvement, did the surgery or did the improvement warrant
5:46
the surgery? And I think that's still an open question.
5:48
So I have plenty of patients who started exercising after they got their pectus done.
5:54
And I don't think it was because they couldn't. I think it was that they wouldn't.
5:58
Now, there is a completely separate
6:00
group of people who either have severe pectus or who have symptoms.
6:05
So the majority of these kids, you will look at their chest and you go,
6:09
how can you not have symptoms from that? And they don't.
6:13
And even ones that do exercise often will say that they exercise just as well as their friends.
6:19
But those with severe pectus or those with symptoms, which are typically,
6:23
and we can get into the serious ones, but a mild shortness of breath or pains,
6:29
essentially, around that area, that's another indication.
6:32
And I just can't imagine with, I know you have three kids, and I have three
6:36
kids too, and my daughter is a teenager now.
6:40
And just wanting to not be different from anyone else, just what a strong feeling
6:46
that is, especially for teenagers.
6:48
Is that enough? Tim. Oh, that's absolutely enough.
6:52
And I have seen the spectrum of people who come in and the kid has a relatively
6:58
severe pectus, one that certainly falls in the category that you should operate.
7:03
And the parents are far more concerned about it than the kid.
7:06
And my answer to them, honestly, is when they want this operation,
7:11
we'll do it. Now, there are caveats.
7:13
The ideal time to do the operation is about when they're 14 or 15.
7:17
For pectus excavatum, for carinatum, really there are some operations,
7:22
but really bracing is by far a better technique.
7:26
So from a standpoint of when to treat these patients, it's important to follow
7:31
them longitudinally, and there's never an emergency.
7:34
The ideal time to repair it, though, is around that 14 to 15 age mark.
7:39
We'll get into the techniques and the evaluations, but you're done with your
7:44
treatment around when they're 18 or 19, and by then their chest is now fully
7:48
ossified. It's going to stay where it is, and so recurrence is much lower.
7:53
But there are actually, my oldest patient so far has been, I put two bars in a 21 year old,
7:58
and have several colleagues, and as we grow the practice actually here,
8:02
I anticipate we'll be doing some more adult pectus, but that'll,
8:06
I'll ask my adult colleagues to help me as well.
8:08
When you get to a fully ossified adult chest, they're not as springy as kids,
8:12
and sometimes you just need a partner to handle the load as it is.
8:17
And talking about growing, the practice growing, you see patients,
8:21
of course, at University Hospital, and you do surgeries there.
8:25
And then also at the University Hospital Morgan's Wonderland location here in San Antonio.
8:30
So here in San Antonio at Morgan's, at their multi-assistance center,
8:35
University Health now has a surgery center that we take care of children and adults.
8:39
We focus on patients with special needs, but not exclusively.
8:43
So I do operate out there. We do not have a clinic out there,
8:46
and this is the kind of, these operations have to be done in the main hospital,
8:49
but it's certainly a center that I'm getting busier at and we're very proud of.
8:53
And we have a lot more to cover, but also wanted to mention that you volunteer
8:58
your time for a program that's an incredible program called Fresh Start.
9:03
It's free surgeries for families who need it.
9:06
And it's for anyone in the world, any of our listeners, if you know of a patient
9:11
who can't afford certain surgeries, they could be a candidate for this.
9:15
Yeah. So www.freshstart.org is an organization originally based out of San Diego.
9:22
We've now been partners with them for about almost for about three years.
9:27
And while I think originally the intention was largely cleft care,
9:31
cleft lip and cleft palate, unfortunately I was given the ball and no instructions.
9:36
And so we've actually been doing a lot of different things.
9:39
We've done things, simple cases like removing just a pre-auricular skin tag
9:44
and a five-year-old that was from Houston, but insurance wouldn't cover it and
9:48
the family didn't have $8,000.
9:49
To complicated cleft surgeries and kids from internationally to kids that are
9:56
here in Texas that, for whatever reason, are not eligible for insurance.
10:00
And we've done burn contractures. We've done...
10:04
Orchiapexis, hernias, and so really anything, sort of the skin in its contents
10:09
that fits into that elective category. And it's been a real success.
10:13
We're continuing to grow it.
10:14
And there's several centers in the United States, not just here in San Antonio.
10:19
Well, San Diego and us, Chicago had a center for some time.
10:23
It's now being restarted. And we also have some affiliation with partners in South Dakota.
10:29
And travel's covered as well, right? Absolutely. The hardest thing to explain
10:33
to people is that it's actually free if the families do through a simple application,
10:39
which is actually in English, Spanish, and now Pashto for our population.
10:42
If they're accepting of the program, the pre-op visits, the intra-op,
10:46
the post-op, if the kids need therapies afterwards, all of that is covered,
10:50
including travel and staying here in San Antonio.
10:53
The biggest question we always get is, is it actually free? And it really is.
10:57
And it's doctors and nurses.
10:59
Everyone's volunteering their time on the weekends. Yep.
11:02
Amazing. And are the patients prioritized based on need, but anyone in the world
11:09
can apply, or United States?
11:12
I would say we prioritize based on medical need and how far you are from Bayer County.
11:17
So medical need obviously will trump anything, but in the order of things there,
11:25
then we just start with the folks who are here and then further on and further on.
11:28
And as we're building the program, we've been blessed that we haven't run into
11:32
having to prioritize anyone based on location because we can go straight through
11:37
on medical need and get things done very quickly.
11:40
Very nice. Anyone in the world that can apply, we certainly prioritize those
11:45
in Bayer County and Texas, but there's no limit.
11:49
Ian, when is imaging such as CT scan or MRI indicated, and how do you interpret
11:54
the Howler Index in practice?
11:58
The pre-op evaluation for these patients, or rather the evaluation of pectus
12:03
patients is, it's evolving, but I think we have some things that are fairly standard.
12:08
So pectus carinatum, so pigeon chest, it really doesn't need truly any imaging or any evaluation.
12:15
I'm happy to see those patients. We go through how the bracing is handled,
12:20
but actually the UT orthotics program here just has a fantastic bracing lab.
12:25
And so the eval for the pectus carinatum patients is really very minimal.
12:31
It's pretty much a referral and that's it. And we're happy to take a look at them.
12:35
In the patients that have a carinatum, and this becomes a discussion between
12:40
a pediatrician, the patient, the family as to, you know, if this is starting to get deeper,
12:46
it's time for you to see a surgeon, that is very different from it's time for you to have surgery.
12:51
It's just time for you to see a surgeon. There are certain checkpoints that
12:56
you wanna go through and things that you wanna check out.
12:59
And so the Haller Index is something that we measure on CTs.
13:03
So if I were in the office and had a patient and I've been seeing them now for
13:07
several years and their pectus excavatum seems to be worsening or growing as
13:12
it were, then we would see them in clinic and we'd order a series of tests.
13:17
Ones that an AP and a lateral test X-ray are not useful.
13:21
So they're not really able to determine the things that we need to know.
13:25
A non-contrast CT scan of the chest is the gold standard for us still.
13:29
There are some experimental imaging techniques that don't use that,
13:34
but I think that is still considered by far the gold standard,
13:37
especially when you're using low radiation scanners like we have.
13:40
And that allows us to determine the Haller Index. And the Haller Index is essentially
13:45
how wide is your chest divided by how narrow is it at the deepest point of your pectus.
13:51
And so if you kind of go back to fourth grade math on that, which sometimes
13:55
I have to, well, if your chest is wide, but it's really, really narrow at the
14:00
middle and the pectus is deep, then that will be a bigger number.
14:04
And so the Haller Index of 3.25 is what everybody has sort of agreed is that's
14:10
the cutoff for when you would start to consider repair or that's considered
14:14
moderate pectus excavatum.
14:16
What's considered severe seems to be within, you know, everyone's purview or everyone's opinion.
14:23
The one thing that was something actually that I had forgotten until a long
14:27
time ago and I was thinking about this talk, it's actually really important
14:30
you do the CT scan at end expiration,
14:33
because you can actually get a 30% increase in your Haller index by taking the
14:40
imaging at end expiration.
14:42
If you kind of think about it, okay, that's when the chest is narrowest from
14:46
front to back is going to be at end expiration.
14:49
And so that's an important piece. The other evaluation that we always get is a standard.
14:56
TTE, an echocardiogram, and that's looking at the structure of the heart.
15:02
And really, the fact that the heart is being compressed by the sternum is essentially
15:06
irrelevant. We know the heart's being compressed by the sternum because we can see it on the CT scan.
15:11
But what you're really looking for is any kind of structural abnormalities within
15:15
the heart, in particular, Marfan syndrome.
15:18
Now, pediatricians listening to this are going to be much more attuned to how
15:22
to diagnose Marfan syndrome than I am.
15:24
But one of the things that we always want to make sure is that there's nothing
15:28
structurally wrong with the heart.
15:31
And for a Marfan's patient, obviously, we're looking for aortic root dilation,
15:34
but also anything else, because once we do a pectus excavatum repair,
15:40
for three years, you shouldn't be going back in there.
15:43
And so if, for example, there was something that could be wrong with the heart,
15:47
we want to make sure that that's the case.
15:49
But sometimes families will get a echocardiogram report that comes back and
15:54
says normal, that the heart is normal.
15:57
And that's okay. That's actually what we want. It doesn't mean that you don't have pectus excavatum.
16:02
It just means that your heart is structurally normal. And that's actually what we're looking for.
16:06
There are some other evaluations. For a long time, I was trained that you had
16:12
to get pulmonary function testing.
16:14
And the reality is, is from a surgical standpoint, if you have a Haller index
16:18
more than 3.25 and you have symptoms or you want your pectus excavatum repaired,
16:24
barring any other contraindications, that's what you need.
16:28
The pulmonary function testing, if you suspect asthma or some other underlying
16:34
pulmonary issue, then certainly you can get that.
16:37
But generally from a history, if we have kids that don't take inhalers,
16:41
don't really have any shortness of breath issues, I don't think it's worth it.
16:46
Why, Ian, is age 14 and 15, why is that the ideal age for the surgery?
16:51
So the way that we do this surgery, we can kind of get into it later,
16:55
but a NUS procedure, it requires putting a bar in the chest, and now often two.
17:01
And titanium or what is it? So the original ones are made out of nickel and
17:05
some are still made out of nickel. Others are made out of titanium.
17:09
And so it's putting a bar in the chest with a stabilizer and then leaving it there for three years.
17:14
So the ideal time to do the operation is when the child has a pliable enough
17:20
chest that you can pop it out.
17:22
But it is going to ossify
17:25
and it is going to stay where you left it
17:28
when you take the bar out now personally i always over correct i always bend
17:33
my bar a little bit steeper so that their chest actually sticks out just a touch
17:38
at the end of the operation and my goal for that is so that three years later
17:42
when we take the bar out if their sink chest sinks down another 10 or 15 percent,
17:47
it won't make any kind of difference.
17:49
If you do the operation too early, there is truly a risk of recurrence.
17:53
If you do this, say, when the children are 10 years old, now they're 13,
17:57
then they get another growth spurt, and now they've got pectus excavatum again.
18:02
I mentioned before, we're now doing this in adults who desire it.
18:06
The difficulty there is it's always two bars, it's a less compliant chest,
18:11
and it's just a lot easier to do in teenagers.
18:15
Ian, let's talk about functional significance. You touched on cardiopulmonary function.
18:22
How do these conditions affect cardiopulmonary function, and what are the latest
18:26
insights about long-term consequences if left untreated?
18:31
There are the easy ones. So the easy ones are the kids that have a symptomatic
18:37
arrhythmia and a pectus excavatum, and there have been multiple case reports
18:42
of fixing the excavatum and the arrhythmia gets better.
18:45
There have been, if you have strong evidence of right heart compression,
18:49
so even by echo, the echo is normal, but the right heart is significantly compressed,
18:54
and there's evidence of that.
18:56
If you have syncope or presyncope, and I read this one, I've never seen a pectus
19:01
this deep, but actually dysphagia,
19:04
so actually difficulty swallowing because the pectus is so deep that the esophagus
19:09
is squished by the heart, And those are all, those are the easy ones that needs,
19:13
that repair needs to be done.
19:15
For what we do not know is truly what are the long-term consequences of an unrepaired
19:22
pectus beyond the cosmetic.
19:25
What we do start to see in some of our adult patients is that while that pulmonary
19:30
function testing that you did when you were a teenager or a young adult really
19:34
doesn't change that much. and their exercise capacity doesn't change that much.
19:39
But remember, they're teenagers. They got an awful lot of reserve.
19:42
What we really don't know is when you're 40 or you're 50, and now your reserve is much less.
19:48
If exercise capacity is important to you, then you may need a repair of that pectus excavata.
19:54
And so we do, there are centers that do this in adults. We are actually,
20:01
I think, moving towards that here.
20:03
There was someone in Austin that used to do this in adults.
20:06
They're no longer there. So myself and Dr. Barbanel and Dr. Gauthier in CT surgery
20:10
are looking at doing these more often in adults.
20:13
And there are some challenges to that, but the technique is more or less the
20:17
same. It's just a little more, you got to eat your Wheaties beforehand. hand.
20:21
And I think moving forward, as most of these kids are repaired as teenagers,
20:28
the question may become moot in the next 10 to 15 years because there just won't
20:32
be that many adults walking around with an unrepaired pectus.
20:36
The other issue is that we'll talk about vacuum bells in a bit,
20:40
but vacuum bells don't work great in children and they don't work at all in adults.
20:44
And so if you don't do the operation, you know, you get what you get.
20:48
Now, there are actually implants that people can get that will hide your pectus excavatum.
20:55
And so in somebody who, for some reason, may not be a surgical candidate,
21:00
but wants a cosmetic, then that can certainly be done, but they don't affect
21:05
anything underneath. They just make your chest look better.
21:08
Wow, it's so interesting. What do we know about the cause of this?
21:13
Cause is? We don't. I mean, I think the best answer is we don't.
21:18
We do know that there is an association of pectus excavatum and Marfan disease, Marfan syndrome.
21:24
And so 40% of patients with Marfan syndrome will have a pectus,
21:31
some kind of pectus abnormality, 40 to 50%.
21:34
But only 5% of patients with a pectus abnormality have Marfan syndrome.
21:40
So even though we always do an examination of the patient, their eyes,
21:44
their joints, and we do that echocardiogram looking for Marfan syndrome,
21:48
it's extremely rare for me to see an undiagnosed Marfan's patient who has a pectus excavatum.
21:54
We do see an association also with Marfan's scoliosis, and it's very common
22:01
for us to have pectus patients that have a mild scoliosis,
22:04
but we also feel like sometimes fixing the pectus helps straighten their spines out a little bit.
22:10
And there is controversy in our groups about which should you fix first if you
22:15
need to, the scoliosis or the pectus, and at this point, I think the jury's still out on that one.
22:20
Ian, are there particular symptoms or exercise limitations that should prompt
22:24
earlier referral to surgery?
22:26
Certainly, if you have exercise limitations.
22:30
In my practice, in really asking these questions to patients,
22:35
I think the patients have fallen into, my experience has been three categories.
22:39
The kids that don't exercise, so they don't know whether they have limitations
22:43
or not, and I have to be honest, that's probably the majority.
22:47
It's skinny, slouchy kids that like to play video games. There are also,
22:51
though, a large number of kids who have no limitations whatsoever.
22:56
You look at their chest and you cannot understand how they have,
23:01
frankly, physiology that's way better than mine at 40-something years old.
23:06
And then there are kids that are symptomatic. And the ones that are symptomatic,
23:10
if you've done a careful check, okay, this is not asthma-related.
23:15
And their symptoms fall into the bucket of pain, pain around the sternum itself,
23:20
pain with the ribs, or shortness of breath with significant exacerbation.
23:24
Those are, that group of patients are probably the ones who are going to get
23:28
PFTs, because you're going to want to make sure that you're not missing an underlying
23:32
lung issue that's being masked somewhat by focusing on the pectus.
23:37
Ian, let's talk about treatment and referral. Can you compare the NUS procedure
23:42
and the Ravitch procedure? what determines which approach you recommend?
23:47
The ravage procedure was developed first and is some people think is,
23:52
you know, is a historical operation, but it's absolutely not.
23:56
It is much less common nowadays, especially after the NUS evolved into being
24:01
a thoracoscopic assisted operation. So we do it with cameras.
24:05
Used to say that the NUS surprisingly hurt the patient more and the ravage hurt the surgeon more.
24:11
So the way the ravage is done is that If you can imagine, you make an incision
24:15
over the sternum, and in that, you take all of the costal cartilages along the
24:21
edges, and you actually break them.
24:22
And that helps you also do a
24:25
wedge of the sternum. So now you're able to more or less pop the chest up.
24:30
And in doing so, as long as you preserve the surrounding tissue of the ribs,
24:34
they will grow back, and they will grow back with the chest up.
24:39
But there used to be a problem when it was invented of recurrence of the chest sinking back down.
24:44
And so one idea that one of the surgeons has was to put a bar behind the sternum
24:49
and attach it so that it would not sink back in.
24:52
And then there truly was one person, Don Nuss at King's Hospital,
24:56
Hospital for the King's Daughters in Norfolk, came up with the idea of,
24:59
well, what if I just put the bar in and didn't do any of the other stuff?
25:03
And thus there came the Nuss.
25:05
Now, I would say, I don't have any numbers, but if I told you it was 95% of
25:10
the operations, I would say that sounds about right.
25:13
But I've actually assisted Dr. Abarbanel, our cardiac surgeon,
25:17
in doing a ravage procedure, and so has Dr. Gauthier, and they've done several.
25:22
And I think the real role for the ravage is in kids that have very asymmetric pectus.
25:27
They're very sloped to one side or the other, and that the advantage of the
25:32
ravage is being able to smooth that chest out a little bit better.
25:35
The other is that you can do a ravage procedure for a failed NUS procedure.
25:41
I wouldn't want to have to do one of those, but if you had to, you can do that.
25:46
It is very, I would not suggest ever trying a NUS procedure after a ravage because
25:54
the scarring in there is, it's dangerous.
25:57
This is all such great information, Ian. Thank you so much.
26:01
What's the role of non-surgical treatments like vacuum bell therapy or bracing
26:07
and which patients respond best?
26:09
So in pectus carinatum, there, as I said, you can go on the internet and find
26:14
operations for pectus carinatum, but bracing is by far the gold standard.
26:20
And just like anything else, compliance is the key.
26:23
So if you have, we call it dynamic compression bracing. So our orthotics team,
26:29
I'll meet with the patients and kind of explain how things go,
26:32
and then we'll refer them to UT Orthotics.
26:34
Those guys are great. And what it really is, is that the patients wear essentially
26:39
a funky strap that goes around their chest, and it has a pad on the back and a pad on the front.
26:45
And as you tighten the brace, it applies a little bit more pressure to their sternum.
26:51
And now the braces can actually measure them.
26:54
I've heard, although I have not seen, there are some Internet of Things ones
26:58
that will actually tell you how long the patient's been wearing it, so they can't cheat.
27:03
But that dynamic compression slowly pushes the
27:06
sternum in into a more normal position and
27:09
the results can actually be excellent but it
27:12
does require one to two years of wearing it and you start out wearing it you
27:18
know an hour a day two hours a day but essentially wearing it almost all day
27:23
long i mean 23 hours you know not when you're showering and not when you're
27:26
playing football is really where the most benefit comes.
27:30
They're actually quite small and unobtrusive. If you have a kid wearing a loose
27:33
T-shirt, you would never know they had a brace on.
27:36
And so if they need to be taken off, obviously for certain times, that's reasonable.
27:41
But bracing works really well when you follow the protocol. So you really have
27:47
to have a very motivated patient.
27:50
And a teenager with a small pectus excavarianotum who's lived their whole life
27:55
this way might not be the best candidate.
27:57
The downside is, of course, once they turn 18, it doesn't work as well because
28:01
their chest is pretty much where it is.
28:03
What is your typical preoperative and postoperative timeline?
28:07
How long is recovery and what should pediatricians watch for post-op?
28:12
So a lot of that has recently changed. So we have adopted kind of a three-prong
28:18
approach in the OR for our Excavatum patients.
28:21
And before I do the operation, I have to send a shout out to vacuum bells.
28:25
So if you go to walmart.com, because that's where we get them from.
28:30
Yeah, there was actually the original manufacturer was in Germany, was Klob.
28:35
But now you can actually get on walmart.com, look up Pectus Excavatum vacuum
28:40
bell, and you will see something that looks like the mask you put at the end
28:45
of a bag valve mask device.
28:47
And what it has is a little tiny pump that's connected to it and it's shaped
28:51
in a bell. And in fact, there's a boy's version and a girl's version.
28:54
So we're putting this in teenagers and you can imagine there are some things
28:58
that kind of get in the way up there.
28:59
And what the patient do is we have a protocol that has been developed and is
29:04
a mishmash of a couple of things, mostly,
29:07
Shriners and also some great data out of China, where you start by applying
29:11
this thing and you suck the air out of it and it elevates the chest a certain
29:15
amount and you wear it for a couple hours and then you take it off.
29:19
And then you keep doing that and you increase the amount of time.
29:22
Now, it does create a very big bruise for the first time as you're setting it
29:27
up, but afterwards the bruise goes away and the kids get used to it. Same thing.
29:32
You have to wear it for a long time. It's usually a couple of years and it doesn't work very well.
29:38
About a third of patients will say they've had excellent or very good results.
29:43
And what I tell parents is those are kids that have a very, very mild pectus.
29:47
Maybe their Hallorindex is certainly less than three. They really don't have
29:51
any symptoms or they're too young.
29:55
So we've actually offered vacuum belt therapy, although the family's decided
30:00
not to go with it for the moment. But I have a seven-year-old with a very deep pectus.
30:04
And we can certainly do the operation when they're older. But if we can get
30:08
a couple more years before they have to, and if that chest is up.
30:12
But again, if you can't get a teenager to be compliant, try getting a seven-year-old to be compliant.
30:17
Maybe better. Yeah, it's hard to say. So we tell folks that the vacuum belt
30:23
works really well when you're very young to get you to an operation.
30:28
Or when you really don't need an operation, but you do want something.
30:32
And you want, again, you want that chest to get up and stay up before you've turned 18, 19.
30:38
From the operative standpoint, it's typically, I have two visits with patients.
30:44
I have the first visit, which is usually about 45 minutes and goes through all
30:47
the options and all the everything.
30:50
And the next step is the, well, do you want to take the next step?
30:53
And the next step is a CT scan, an echocardiogram, and perhaps any other tests
30:57
that we need. The second visit, we kind of go over the operation and just say,
31:02
these are all the things that we do.
31:03
And at that point, the families make a decision. This is a very,
31:07
very much a summer operation. So I do this operation a lot, starting right after school ends.
31:13
And because essentially, you know, that that those months in June and July get
31:18
it done while the kids are out of school.
31:20
And the operation, as I said, we're really on a three-pronged approach.
31:24
So the first piece actually begins pre-op. We used to give these kids gabapentin
31:29
and start them on gabapentin before the operation.
31:32
We don't do that anymore because our anesthesia colleagues are able to do erector spinae blocks.
31:37
And the beauty of an erector spinae block is when they inject local onto both
31:42
sides of the chest, it acts for a short period of time, but we only need it
31:47
during the operation in that really immediate post-op period.
31:50
So that decreases huge in the amount of narcotic.
31:54
And you give a teenage boy morphine and you might as well just stick a cork
31:57
in his butt because he's not going to poop for days.
31:59
And so that's one of the things that we're really trying to reduce.
32:02
The next step that we've done from a safety standpoint is we've started using
32:06
a device called the Ruletract. It also is called the Skyhook.
32:10
But if you Google Pectus Skyhook, you will see something that looks like a medieval torture device.
32:16
Oh, goodness. But what we do is actually put a moderate-sized clamp through the sternum.
32:21
And as we put our camera in on one side, you can raise the sternum up under direct vision.
32:26
So you can actually see the sternum coming up off the heart,
32:29
which makes the plane that I need to work in so much easier to visualize.
32:33
From a safety standpoint, I put a camera in on the other side,
32:37
and we're able to see exactly where we're going to make the bar go across.
32:40
And then the thing that's completely revolutionized this from a pain standpoint
32:46
is the use of cryoanalgesia.
32:48
So we have a cryoablation tool that you actually...
32:54
A thoracoscopic device that looks like a tube with a little spherical metal
33:00
sphere at the end, and that sphere touches the rib, underneath the rib and touches
33:04
the neurovascular bundle,
33:05
and gets down to about minus 120, and it freezes the nerve, and you have to
33:11
hold it there for about 90 seconds.
33:13
And you do that five ribs on one side, five ribs on the other side.
33:16
So if you start doing the math, it takes almost as long to do the cryo as it
33:20
does to do almost the rest of the operation.
33:22
Really? But when we do the cryo...
33:24
The change is unbelievable. On the way out, we put the bars across,
33:29
flip them up, and secure the bars into the chest.
33:32
And then this used to be five days in the hospital. Kids used to have epidurals
33:37
instead of the erector spinae blocks, and it used to be a struggle to get them out of bed.
33:41
You know, I was telling you beforehand, the last one I did and the one before
33:46
that, the two cases ago, I sent him home on the second day because I just couldn't
33:51
stomach sending him home on the first day.
33:54
And the last case I did was a kid that came from El Paso to see me,
33:58
and we sent him home the next day.
34:00
And truly, he was actually sitting up in bed the evening of his operation and
34:06
smiling and eating. and he was mildly uncomfortable, but he was getting Toradol and Tylenol.
34:13
And I can't say whether he got a dose of morphine or not, but he certainly didn't get much. Wow.
34:18
So now the kids are going home. Then becomes a couple of things.
34:22
While they're in the hospital, we get a visit from PT and OT.
34:24
Because if you can imagine, they've had their chest popped out and this bar
34:28
is secured to their ribs in multiple places, but we have to teach them to move
34:32
without twisting their chest.
34:34
So they actually have to learn to sit up they have to learn to
34:37
get out of bed without twisting at all and so
34:39
that takes a little bit of practice and we like them to do that under supervision
34:43
the complications from this operation are very few very fortunate but one of
34:48
them is the bar flipping back and so trying to get them to take it easy and
34:53
learn not to twist until that bar is well situated is key.
34:58
Kids like I said they leave the hospital the next day or the day after in that
35:04
Kid that stayed from El Paso, we had him stay in San Antonio just for a week
35:07
so I could make sure everything looked good.
35:09
It did, and the next Monday, he took a plane back to El Paso. Actually, they drove.
35:15
And then I tell them two to three months walking is about what you're going to do.
35:21
After two months, they can start to twist. And after three months,
35:24
there is some debate. I will let them do anything because this is Texas and
35:29
kids are going to play football and run into things no matter what,
35:32
whether you tell them to or not.
35:34
There are others who do not allow these patients to play contact sports.
35:38
But I think that if you think about the physiology of the bar,
35:42
what it's doing, where it is and how long after three months.
35:45
If I told you how hard it is to get one of these things out,
35:49
then you'd kind of think about it and go, okay, it makes sense.
35:51
It's not moving once it's in there.
35:53
We do actually often give them a card. They shouldn't set off the metal detectors
35:58
at the airport, but we let them know that.
36:00
And we always warn them about MRI machines. I cannot remember about the MRI
36:04
compatibility of our new borrowers.
36:06
And so the kids, actually after that, You get a six-month appointment to make
36:11
sure you look good, a one-year appointment, which is mostly to remember your
36:15
next appointment, and just make sure that everything is going well.
36:18
And then in three years, it is an outpatient procedure where we open up the
36:22
incisions, bend the bar, and pull it out.
36:25
And then I like to follow the kids for another year just to make sure that there isn't any changes.
36:31
If I feel like a kid was starting to sink back, then I might use the vacuum
36:36
belt to tied them over until things finish ossifying. And that's it.
36:41
The only other significant complications that we see, occasionally there is a bar allergy.
36:46
So occasionally the kids do have an allergy to the metal in the bar.
36:50
I've been blessed. I haven't seen it personally. But if that does happen,
36:54
then sometimes you can get by.
36:57
But sometimes you just have to take the bar out.
37:00
And titanium and nickel, it's not a problem at the airport going through security?
37:04
I don't believe it is, but we give them a card just in case.
37:08
Where they can have special access. Yeah, and they have two incisions on either
37:12
side to let somebody know there's something there.
37:15
And, you know, these are skinny kids.
37:18
Pectus excavatum and pectus carinatum, typically, I've never seen it in a kid
37:23
who isn't skinny or at least average.
37:25
In fact, some of these kids are so skinny, I have to find some muscle to put
37:30
over the bar, you know, find some room to get the stabilizers in.
37:33
So you can actually even feel under their skin where the bar or where the stabilizer
37:38
is in on some kinds. and the kids don't seem to mind it.
37:41
From your perspective, Ian, what are some common misconceptions community pediatricians
37:45
may have about these conditions or their treatments?
37:50
I think sometimes these are things that surprisingly sneak up on somebody,
37:56
that the family has known this
37:58
for years, and all of a sudden it seems suddenly to have gotten worse.
38:03
And that may or may not be the case. It probably is the case.
38:07
And the main thing there is reassurance. There are no emergent pectus operations
38:12
or concerns. And I think we are always happy to see anybody if the answer,
38:18
if the family is in any way unhappy with the answers they're getting.
38:21
Even if you think this is extremely mild, it really wouldn't even warrant treatment. We are happy to see them.
38:28
I also think some of the other misconceptions are about the post-op,
38:34
you know, the post-op time.
38:36
This for people that, you know, myself, I finished fellowship in 2012,
38:40
and the post-op and recovery period has changed radically since that time.
38:47
And so I think that it is, while it sounds and can be a difficult and horrific
38:55
operation to do to somebody, the results in general are actually excellent and have continued.
39:00
And cryo has just made a whole difference.
39:03
Wow. You're making such a difference in these children's lives,
39:07
and it's wonderful to hear all of this information.
39:12
Moving on to interdisciplinary care and outcomes, how do you coordinate care
39:16
between surgery, pulmonology, cardiology, and primary care?
39:20
I think for us, as we grow our practice here in San Antonio,
39:25
a lot of people will talk about or have a chest wall center, for example.
39:29
And I don't think we put a sign out that says that, but I think we are certainly growing that.
39:34
And the reason I'll tell you is actually we get some referrals from cardiology.
39:38
One of my biggest sources of referrals is actually our cardiac surgeons.
39:42
So Dr. Calhoun and Dr. Barbanil will get a referral for a pectus,
39:47
and they may offer a ravage to that patient, but they also are very good about
39:52
offering a NUS procedure done by us. They don't do the NUS in particular.
39:57
And so that has also led to some kids who, you know, things are a little,
40:03
they're not quite straightforward.
40:05
Maybe it's a nuss with something else, or maybe it's a different type of chest wall defect.
40:11
And so we're blessed to have both adult and pediatric cardiac surgery here.
40:16
We're blessed to have the cardiologists, if there is anything that's identified.
40:20
Every so often, you'll find a Marfan's patient, and here we are.
40:24
So as we continue to grow, I'm blessed to have all those specialists that we need around.
40:29
Again, if there are pulmonary issues, then we'll have them see pulmonology beforehand.
40:34
And I have found that most of these kids don't really have any pulmonary issues
40:38
pre-op, but you never know, and I'm glad they're there.
40:41
Are there any emerging techniques or outcomes, data that you're excited about,
40:46
particularly regarding minimally invasive repair, pain management,
40:50
or recurrence prevention?
40:52
I think that really the advent, the erector spinae block and the advent of cryo,
40:58
and now the safety that comes with the skyhook, I think are really that we're
41:01
right there at the forefront of pectus care.
41:05
Some people are doing these as outpatients and
41:08
i think that that that can
41:11
be done i would just as a guy from buffalo new york
41:14
i would say some people are new york jets fans but i wouldn't do
41:17
that and i think that that is something that people may read about and wonder
41:22
and maybe i'll get there someday but right now i just feel like it's an awful
41:26
lot to do to somebody's chest but the fact that you can do it as an outpatient
41:30
is such a statement of what great pain control we're now getting.
41:35
There is another procedure that is extremely new.
41:39
It's called a taulinoplasty, and you may read about something called a pectus up.
41:44
And what that is, is about a four centimeter incision over the sternum where
41:48
you put a bar under the skin on the outside of the chest and actually screw
41:53
it into the sternum and the ribs.
41:55
And that lifts the chest up. The problem is that that's permanent.
41:59
So it's a, it's a generous incision. I mean, four centimeters is not that big
42:03
truly, but it is an incision in the very middle of the chest and put something permanent in,
42:09
which I think maybe in the adult population, that could be a real option.
42:14
But I think that for the moment, we're not seeing the virtue of that over something
42:19
that's in for three years and then it's out and it's gone.
42:23
What's your advice for pediatricians, Ian, when reassuring families or discussing
42:27
prognosis during those first conversations?
42:32
I think the main point is to say that this is really, truly a decision that
42:40
is made between the pediatrician, the family, the patient, and myself.
42:46
If you have appendicitis, I can give you a lot of options, but guess what?
42:50
Most of them are going to end in an appendectomy.
42:53
And if you have a broken leg, well, we're going to fix that. Yes.
42:56
This is one of those things where we're taking usually an adolescent and putting
43:02
them through a big surgery.
43:04
It is much less, I think, and much more comfortable than it used to be.
43:09
But a lot of times the family may really want this and the patient doesn't or vice versa.
43:15
But it's one of those things where I think we have the techniques to make this
43:20
safer that if you have a 12-year-old or a 13-year-old who's just not ready, that's okay.
43:25
That's okay. I have a lot of patients who I've seen once and I say, you know what?
43:30
You're not ready now. I've got your studies. We might repeat the echocardiogram
43:35
later, but if the CT scan shows a big Hallor index, it's not going to get better
43:39
over time. It doesn't get better.
43:42
So if you want to come back and see me in a year or two, that's okay.
43:45
And sometimes they get a little bit later. You know, you have a 16-year-old
43:49
or a 17-year-old who now is realizing,
43:52
hey, I'm going to college or the military, and then we have to have a discussion
43:56
about, okay, you cannot forget to have this thing removed because you wouldn't believe it.
44:01
But there are people that actually forget they have a bar inside them and forget
44:05
that, you know, I get busy with life and having this thing that's never bothered
44:09
them in the last three years.
44:10
So there's some of that conversation. But.
44:13
What's on the forefront? What's new that you would like to talk about before we wrap up, Ian?
44:19
I think there is technology that I think that is being developed,
44:24
and the question is, can we do this non-invasively?
44:28
And there are techniques that are being developed of using implantable magnets,
44:35
and then you could imagine wearing some kind of magnet on one side and a magnet
44:40
on the other that lifts the chest up.
44:43
To that, I would say, well, one of the issues that we know we have with that
44:47
is the issue with vacuum bells of that you can get the chest out,
44:50
but keeping it there over the long term is the real issue.
44:54
And so I think from a technology standpoint, that will certainly be something that's on the horizon.
45:01
I don't know that we'll ever solve the exercise debate.
45:04
The people that love to do this operation will tell you how wonderful it is.
45:07
And yes, I love to do this operation, but I'll be the first to admit that if
45:12
your child doesn't exercise now and they're not going to exercise later,
45:15
then they'll probably be fine.
45:18
And I think the other is the recognition of the psychosocial aspect for this.
45:23
You know, the idea of sending kids for a psychological evaluation was something
45:27
we never did before. And now if the family feels like that's an important thing,
45:32
we'll absolutely do that. Here we go.
45:36
Ian, is there anything else you want to mention before we wrap up that we didn't cover?
45:40
It's really a privilege to take care of these kids. They're a very,
45:44
I have to be honest, I don't know why, I find them really funny.
45:47
Like, Pectus kids are just funny. I mean, I don't know what about them that
45:51
makes them funny, but...
45:54
They have a great sense of humor. The first time they wake up in the recovery
45:58
room, and you'll stand next to them, and I will, when they're awake enough,
46:02
I'll tell them, lift your gown up.
46:04
And they will lift, and they will look down at their chest, and they will smile.
46:09
And they will just look down and go, they got that, hey, I look good.
46:16
I love it. And it's worth it. It really is.
46:20
And there are risks to this operation, but I think we've spent years trying
46:26
to mitigate them and make it better for patients. And I'm really proud of where
46:30
we've come just in the last 10 years.
46:32
Do you want to mention those risks? I think the issues about bar flipping, which is,
46:40
again, unusual, but now that we'll probably move to a two-bar system that doesn't
46:45
increase the number or the length of the incisions, I guess you could have two
46:50
bars flip, but they're actually locked together on the inside of the patient.
46:54
So I can't imagine physiologically how that could even happen.
46:59
And if you read, you know, thousands of this operation have been done safely,
47:02
but that one risk of cardiac injury is a thing that you have to tell a parent.
47:08
I mean, I can't, if I don't tell a parent that that exists as a risk,
47:13
first of all, it makes sense. If you think about what we're doing, of course it exists.
47:17
But the skyhook and the ability to mitigate that risk is just,
47:21
it's a real, I think it's just, it's made it better.
47:26
I know you're doing lots of adventurous things, a trip to San Diego.
47:31
We went to the Children's Hospital Association meeting and the surgeon chiefs
47:36
group there, and I was very fortunate.
47:39
Some of the Navy pediatric surgeons out in San Diego are colleagues and actually
47:44
one trained at the same institution at Cohen Children's where I trained.
47:48
And so three of us were very fortunate to actually take a tour of the Abraham
47:52
Lincoln aircraft carrier while it was still in port, which was just a blessing.
47:56
You get to see the operating room that they use at sea. Wow.
48:00
And you learn all sorts of things that you think operating on children in the
48:04
middle of San Antonio is hard. Try doing it in the middle of the Indian Ocean.
48:08
So, wow. It was just a fantastic trip and really reminds you all of the amazing
48:13
things and the amazing risks that the folks in armed forces do.
48:16
So it was great. I wonder what they do when it gets choppy.
48:20
Actually, they have to ask to stop the boat. Really? Yep.
48:24
And it apparently is often a negotiation between the captain and the surgeons.
48:29
And it's a fascinating experience to learn what they have to do sometimes to
48:35
take care of those soldiers.
48:36
But fortunately, they seem to have had great results and done well. Wow. Wow.
48:41
Here's the segue. I went through some turbulence in life and I just wanted to thank you.
48:46
And I'm just going to try not to cry as I thank you for helping me after my
48:49
leg was shattered on a mountainside snow skiing about seven months ago.
48:55
And your call, taking my call and helping me, walking me through options and
49:00
what to expect and just being there was just, I can't tell you how much it helped
49:06
me. So I was glad I could help.
49:09
I love to promote having a life outside of medicine to recharge.
49:15
We don't like, we don't say balance, right? It's more about like unplugging. Who has balance?
49:22
So skinnier than the last time you saw me. I'm 20 pounds down.
49:26
The San Antonio Marathon is a month away. And at 49 and a third years old,
49:32
we'll force the kick of the can. We'll see how this one goes.
49:36
So you're going to do the whole thing? Yeah, we'll do the whole thing.
49:39
Hopefully running it and not crawling, but we'll see.
49:41
My children are 7, 9, and 11, so I spend a lot of time chasing them around.
49:46
And really, in the last little while, my wife, Dr. Ali Garcia,
49:50
has become the medical director of a foundation called LEAP.
49:54
It's Life Enhancement Advancement for People. And they do international cleft missions.
49:59
They go and operate in Belize. She does otoplasties in Mexico and actually has been going to Zimbabwe.
50:06
So it's been great. It's something she and I did as residents.
50:09
And now we've really come full circle where she is the medical director.
50:12
But for those of your audience that know me, me versus my children,
50:18
for 10 days while my wife is in Zimbabwe, they could probably make a movie out
50:21
of it. That's hilarious.
50:25
Well, I know you're going to do great. If anyone can do the marathon,
50:29
I know you can. Thank you.
50:31
Dr. Ian Mitchell with University Hospital and UT Health San Antonio,
50:36
thank you so much for being here on Pediatrics Now.
50:39
Been great. Thank you very much. We will have an episode in our sister podcast,
50:43
Pediatrics Now for Parents, that will be much shorter and where Dr.
50:49
Mitchell will be talking directly to what parents should know about this.
50:53
And it's meant to be one less thing you have to say in the exam room.
50:57
If you want, you could mention to your patient, to the family,
51:01
we have this podcast, Pediatrics Now for Parents, where there's this episode.
51:06
Coming up next week, what can AI do for your practice?
51:10
Advice from the Chief Medical Officer at Microsoft.
51:15
I'm Holly Wayment. Don't forget to click on the link for free credit,
51:18
and I'll see you next week.
51:20
I just really want to send a shout out to Christian McAvoy, to Connor Arellano,
51:27
and to Sophia Schemmerhorn, who are three Navy surgeons, two pediatric surgeons,
51:32
and one just about to be freshly minted general surgeon who have served on the
51:37
USS Abraham Lincoln and who gave some pediatric surgeons a tour of a lifetime.
51:43
And thank you, not just for your
51:45
service for the country, but for your patients. It's incredible. Yeah.