Online Health Chat with John DiFiore, MD, and Anthony DeRoss, MD

Wednesday, March 1, 2017


Description

Pectus excavatum is an abnormal development of the rib cage in which the breastbone grows inward, resulting in a sunken chest wall. Commonly known as “sunken chest” or “funnel chest,” pectus excavatum can be corrected with the Ravitch procedure or the minimally invasive surgical technique called the Nuss procedure.

In contrast, pectus carinatum is a condition in which the breastbone protrudes more than usual. The condition is sometimes called “pigeon chest.” Pectus carinatum has two treatment options, bracing and surgery. Surgical correction for pectus carinatum involves a technique called the Ravitch procedure.

Both deformities are more common in boys. Although babies are born with the conditions they are often not noticed until the children reach puberty (teen years).

Join Dr. John DiFiore and Dr. Anthony DeRoss for answers to your questions about pectus excavatum and carinatum including minimally invasive and noninvasive treatment options.

About the Speakers

John W. DiFiore, MD, FACS, FAAP, is director of the Center of Excellence for Minimally Invasive Repair of Pectus Excavatum (Nuss procedure) and surgical director of the Fetal Care Center at Cleveland Clinic. After graduating cum laude from Dartmouth College, Dr. DiFiore attended medical school at the Columbia University College of Physicians and Surgeons in New York City. He completed a surgical residency at New England Deaconess Hospital/Harvard Medical School, followed by a pediatric surgery and research fellowship at Boston Children's Hospital/Harvard Medical School in Boston. Dr. DiFiore is certified in general and pediatric surgery by the American Board of Surgery.

Anthony L. DeRoss, MD, FACS, FAAP, is certified in general and pediatric surgery by the American Board of Surgery. He specializes in pediatric general surgery and is associate staff at Cleveland Clinic along with assistant professor of surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. After graduating from Carnegie Mellon University, Dr. DeRoss attended medical school at the University Of Pittsburgh School Of Medicine in Pittsburgh, PA. He went on to the University of Vermont/Fletcher Allen Health Care in Burlington, VT, where he completed a surgical research fellowship in 2001 and a residency in general surgery in 2004. In June 2006, Dr. DeRoss completed his fellowship in pediatric surgery at St. Christopher’s Hospital for Children in Philadelphia.


Let’s Chat About Pectus Excavatum and Carinatum


Discussing the Disorders

GratefulMom: In pectus excavatum, are the ribs smaller on one side of the body causing the imbalance? If they are, how does the Nuss procedure correct or compensate for it?

John W. DiFiore, MD, FACS, FAAP: The ribs actually have two parts. The back two thirds are bone, and the front one third is cartilage. In pectus excavatum, the cartilaginous portion of the ribs grows more quickly than the bone, becoming longer and pushing the sternum backwards, creating the "sunken" chest. The Nuss bar pushes the sternum and ribs outward into the normal position and over time, the cartilage and bone reshape and remodel so that when the bar is removed, they maintain their normal position. This is very similar to the way braces work in correcting teeth.

Brock1997: Does working out help cover up the appearance of a chest wall deformity?

John W. DiFiore, MD, FACS, FAAP: Working out does not change the position of the sternum at all, in other words, it does not correct the pectus deformity. It may help the appearance of the chest if the deformity is mild, but in our experience, patients are not satisfied with the appearance of their chests just from working out. Working out will not improve any of the symptoms of pectus, such as shortness of breath or chest pain.

Clara35: Are there any long range effects of having a concave chest, other than cosmetic, as long as the heart tests were okay? Will things change over time?

Anthony L. DeRoss, MD, FACS, FAAP: There is currently no data supporting the idea that living with pectus excavatum will lead to any problems later in life, but some researchers are beginning to investigate this possibility more closely.


Symptoms and Diagnosis

KKnight: What types of test are done to see if your child has pectus excavatum or pectus carinatum?

John W. DiFiore, MD, FACS, FAAP: We will know if your child has pectus excavatum or carinatum simply from a physical examination. A more detailed workup includes a cardiac MRI and cardiopulmonary stress testing to accurately measure the severity of the pectus and measure its effect on cardiopulmonary function.

koober: If a patient, 36, has only 1.5cm between the closest point of sternum and spine, how do you determine if you should fix the spine or sternum? The spine is a double major curve with lumbar bowing outward and thoracic inward.

Anthony L. DeRoss, MD, FACS, FAAP: Patients with pectus excavatum or carinatum often have associated scoliosis. In general, we recommend consultation with a spine surgeon so that any spine surgery can be completed before fixing the chest.

ROEDERE2001: Both my son and I have pectus excavatum. First, is it hereditary? Second, I've never had any medical issues with it, but are there medical issues associated with it or only cosmetic issues?

Anthony L. DeRoss, MD, FACS, FAAP: Pectus excavatum can be hereditary in almost 40 percent of cases. Patients often have significant compression of the heart and lungs from the pectus, causing symptoms such as shortness of breath with exercise, decreased stamina compared to peers and irregular heartbeat. Patients with pectus excavatum can also have chest pain associated with the condition. It's not uncommon for patients with pectus excavatum to feel as if their breathing and stamina are normal before surgery and then realize they feel much improved following correction.

lynnald: I have a 13-year-old son with pectus excavatum. He does experience exercise intolerance, which I have been told is due to this condition. I am not sure to what degree (mild, moderate, severe) it is. I have researched this condition and see that some websites offer exercises to help this condition, such as breathing exercises, push-ups, etc. How do you at Cleveland Clinic feel about this? Are these exercises helpful? Is surgery the only option?

John W. DiFiore, MD, FACS, FAAP: Symptoms of exercise intolerance are very common with pectus excavatum. There is no research showing exercise improves this problem, and our experience supports this. At Cleveland Clinic, we do a comprehensive functional evaluation including cardiac MRI and cardiopulmonary stress testing to determine if the pectus is the cause of the exercise intolerance. If it is, surgery is the best option.


Treatment Talk

Harry91: What can be done to treat pectus excavatum?

John W. DiFiore, MD, FACS, FAAP: We offer two types of surgical correction. Briefly, the Nuss procedure involves making a small incision on each side of the chest and tunneling a bar through the chest to push the breast bone outward to correct the pectus. The Ravitch procedure involves making a larger incision, removing the cartilage responsible for the pectus and flattening the breast bone. Ninety-five percent of patients are candidates for the minimally invasive Nuss procedure.

Elijand: Is there any medical reason why this syndrome should be treated. Is there a down side to not treating it?

Anthony L. DeRoss, MD, FACS, FAAP: Patients should seek treatment if they are having physical (chest pain, shortness of breath) and/or psychological symptoms (depression, embarrassment) from their pectus. If the pectus excavatum is not bothering the patient, observation is perfectly acceptable. There is currently no data supporting that not correcting the pectus will lead to problems later in life, but some researchers are beginning to investigate this possibility more closely.

Tim_boresk: Is the treatment for pectus carinatum different from pectus excavatum?

John W. DiFiore, MD, FACS, FAAP: Pectus carinatum can be treated nonsurgically, with an external brace, or surgically with a procedure to remove the abnormally shaped cartilage. Pectus excavatum will not improve without surgery. For pectus excavatum, 95 percent of our patients are candidates for the minimally invasive Nuss procedure.

Brock1997: For pectus carinatum, what are the pros and cons of brace versus surgery?

John W. DiFiore, MD, FACS, FAAP: The pros of the brace are primarily that it is nonsurgical and completely noninvasive. The downside of the brace is that it must be worn 18 to 24 hours per day for 4 to 24 months (depending on how stiff the chest is). The pros of surgery are that the pectus is immediately corrected, but it does require four to five days in the hospital after surgery and staying out of sports for six months. Surgery also results in a scar on the chest.

Dustyv: What are the pros and cons of the Nuss versus the Ravitch procedure?

Anthony L. DeRoss, MD, FACS, FAAP: The Nuss procedure has the advantage of smaller, less noticeable scars. I personally feel that it is also better at remodeling the entire thorax, as opposed to the Ravitch, which addresses specifically the junctions where the ribs meet the sternum.

VeronicaQtee: For pectus carinatum, how do I decide if my child should get surgical versus nonsurgical treatment?

Anthony L. DeRoss, MD, FACS, FAAP: Both are options for most patients, and the decision depends upon the specific needs of the patient and family.


Nuss Notes

Dustyv: [In the Nuss procedure], is the bar permanent?

John W. DiFiore, MD, FACS, FAAP: The bar is left in place for three years and removed during an outpatient procedure that typically takes less than hour to perform.

Dustyv: Once the bar is removed, is there a chance of the chest returning to its previous state?

John W. DiFiore, MD, FACS, FAAP: The risk of recurrence after the bar is removed is less than one percent.

GratefulMom: How long does the pectus excavatum surgery take? How long does a patient stay in the hospital?

John W. DiFiore, MD, FACS, FAAP: The Nuss procedure usually takes about an hour, and patients are typically in the hospital four to five days.

GratefulMom: What activities are restricted after pectus excavatum surgery?

John W. DiFiore, MD, FACS, FAAP: For the first three months after the Nuss procedure, activity is strictly limited, with no sports, heavy lifting or exercise. After three months, the vast majority of sports and other exercise can be done, including weight training. However, some activities are restricted for six months, such as contact sports (football, soccer, hockey) and sports that require significant upper body rotation, such as golf, tennis and baseball. For competitive athletes, aerobic activities for cardiac conditioning can be done six to eight weeks after the procedure using lower body workouts, such as stationary bikes, jogging and running.

KevinMc: What are the major complications with the NUSS treatment method?

Anthony L. DeRoss, MD, FACS, FAAP: Early complications are rare (each less than one percent) and include infection, pneumonia, bleeding and pericarditis. Late complications are also uncommon (each less than five percent) and include movement of the bar, allergic reaction to the bar and recurrence of the pectus.


Bracing for It

heidi: My son has pectus carinatum. How long do you typically wear the brace to correct this condition, months, years, and for how many hours a day?

Anthony L. DeRoss, MD, FACS, FAAP: Typically, time for correction can range from four months to two years depending on how stiff the chest is. This can vary with the age of the patient, with older patients being stiffer than younger. For most patients, we recommend wearing the brace as much as possible up to 24 hours a day, removing the brace for sports and showering. The longer the brace is worn each day, the shorter the total duration of therapy. Once we measure how much pressure it takes to correct the bump, we can offer a more precise estimate on how long correction will take.

heidi: Are there any people or kids with pectus carinatum on whom the brace is not effective?

John W. DiFiore, MD, FACS, FAAP: One of the advantages of our dynamic bracing system is that we actually measure how much pressure it takes to do the correction. A "softer" chest will correct more consistently and more quickly than a "stiffer" chest. Typically, time for correction can range from four months to two years depending on how stiff the chest is. This can vary with the age of the patient, with older patients being stiffer than younger. We do not exclude anyone from trying the brace, and even a stiffer chest can be corrected.

MaMaBeAr: Can you sleep with the brace on?

John W. DiFiore, MD, FACS, FAAP: You can. However, the brace is less effective while sleeping because the brace moves during sleep, and pressure is not applied uniformly to the sternum, as it is in a standing/upright position. For example, lying on your back will push the front of the brace away from the sternum, decreasing the pressure applied to the carinatum deformity.

StephBlott: Can females wear the brace for pectus carinatum correction? Does it affect breast growth?

John W. DiFiore, MD, FACS, FAAP: Yes, females can wear the brace with excellent results, and we have many female patients in our bracing program right now. The brace does not affect breast development/growth.

lynnald: Hi. My 16-year-old son has pectus carinatum. I have only just become aware of the brace that can be worn for this condition. Would my son still be a candidate at the age of 16, and what testing (and cost) would be involved if I were to bring him to Cleveland Clinic for a consult? We live in Charleston, WV. Thank you.

Anthony L. DeRoss, MD, FACS, FAAP: He is absolutely a candidate for the brace. Testing for pectus carinatum would consist of at least a chest x-ray, with other testing tailored to patients on an individual basis. The cost to the patient depends upon that patient's insurance and the degree to which the brace is covered. Bracing does require routine follow-up on a monthly basis to adjust the pressure as the chest continues to flatten. That interval could be extended to accommodate schedules for patients living further away.


Age Limits

Iversonstreet: I am 29 years old. Is it too late to have the NUSS procedure?

John W. DiFiore, MD, FACS, FAAP: Absolutely not. Approximately 25 percent of our patients are older than 18 years, with the majority of these in their 20s. We have corrected patients in their 30s, 40s and even 50s.

silky1245: Is there an ideal age to have the Nuss procedure? What is recovery like after the Nuss procedure?

John W. DiFiore, MD, FACS, FAAP: The ideal age for the Nuss procedure is 13 to 16 years, and we encourage patients to seek treatment during this time frame if at all possible. Older patients, however, are still candidates for the Nuss procedure, and we have treated patients in their 20s, 30s, 40s and even 50s. Recovery is four to five days in the hospital and approximately two weeks at home on progressively decreasing amounts of pain medication. Adult patients typically require a few more days in the hospital and more time at home on pain medications.

MaMaBeAr: My son is 18 years old. Is it too late for him to get the brace?

John W. DiFiore, MD, FACS, FAAP: No – it’s not too late for him to use the brace, although he may not achieve the same results as quickly as a younger patient. As mentioned in other questions, a "softer" chest will correct more consistently and more quickly than a "stiffer" chest. Typically, time for correction can range from four months to two years depending on how stiff the chest is. This interval can vary with the age of the patient, with older patients being stiffer than younger. We do not exclude anyone from trying the brace, and even a stiffer chest can be corrected.


Closing

That is all the time we have for questions today. Thank you, Dr. DiFiore and Dr. DeRoss, for taking time to educate us about Pectus Excavatum and Carinatum.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.


For Appointments

To make an appointment with Cleveland Clinic’s Minimally Invasive Center for Pectus Excavatum and Carinatum, please call 216.445.1718, or learn more on our website at clevelandclinic.org.


For More Information about Cleveland Clinic

Cleveland Clinic Children’s Hospital is currently one of only five centers in the country recognized for excellence in treating pectus excavatum. When you want qualified, certified treatment for pectus excavatum, look to us to deliver.

Cleveland Clinic Children's is dedicated to the medical, surgical and rehabilitative care of infants, children and adolescents. The staff uses the latest technology and most recent research to achieve the best possible outcomes. Children's has more than 300 pediatric specialists who are leaders in research for cardiac care, neurological conditions, digestive diseases and other conditions. More than 80 of our staff are annually named as "Best Doctors" by their peers. Cleveland Clinic Children's is consistently rated among the "Best Children’s Hospitals" by U.S. News & World Report™.

Visit our website for more information about pectus excavatum.

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