Thyroid & Adrenal
18 year old male presents with pectus excavatum. He denies history of any dyspnoea or chest pain. On examination there is mild pectus excavatum and intermittent wheezing on exertion. Surgery in this patient is indicated if he has:
|A||FEV1 / FVC less than 0.60|
|B||Limiation of maximum inspiration during exercise|
|C||Peak work capacity 60% of expected|
|D||Functional work capacity 80% of expected|
Depression Deformities (Pectus Excavatum)
a. Pectus excavatum (also called funnel chest) is the most common chest wall deformity, occurring in 1 of 400 children.
b. Males are affected more frequently than females (4:1).
c. More than 30% of cases have a family history of chest wall anomalies.
d. Pectus excavatum arises from imbalanced or excessive growth of the lower costal cartilages, causing posterior sternal depression.
e. The depression can often be deeper on the right side than the left, causing a rotation of the sternum.
f. Typically, the defect is diagnosed within the first year of life and worsens over time.
g. A wide range of depression abnormalities is reported, varying from a mildly depressed sternum to sternal depression abutting the vertebral column with displacement of mediastinal organs, including the heart.
h. Evaluation of baseline pulmonary function can be obtained with pulmonary function testing, exercise radiologic or physiologic studies, and ventilation-perfusion scans.
i. To assess the severity of this defect, a variety of methods have been used based on measurements obtained from chest radiography or chest computed tomography (CT).
j. Most methods use the distance between the sternum and spine to create a ratio to compare the depth of the depression.
k. The indications for operative intervention include cosmesis, psychosocial factors, and the presence of respiratory or cardiovascular insufficiency. Poor self-image is an important concern for many patients, particularly children and adolescents or young adults who are taunted by peers.
l. Because of these concerns, early repair is supported, with best results reported between 2 and 8 years of age.
m. Surgical repair of pectus excavatum includes 5 procedures.
1. The first involves repositioning the sternum anteriorly by sternal osteotomy.
2. The second is a modification of this procedure that involves supporting the repositioned sternum with a posterior strut (sternal strut)
3. The third technique (sternal turnover) involves removing the sternum and repositioning it in a front-to-back rotated position before stabilization.
4. The fourth technique for correction employs a Silastic mold that is implanted into the subcutaneous space to fill the defect without altering the thoracic cage.
5. The fifth technique is a minimally invasive procedure that avoids cartilage resection or sternal osteotomy, but utilizes an internal posterior sternal support. This technique has gained popularity during the past decade, but is less applicable in older patients and those with asymmetric deformities.