What are the state-of-the-art solutions for thoracic cavity malformations
In the majority of cases, a funnel-shaped depression of the anterior chest wall develops, especially during puberty. The cause lies in an insufficiently mechanically firm sternum in the context of the growing organism. In about 30% of patients, there is a funnel chest patient in the family. Men are affected four times more often than women.
Prim. Univ. Prof. Dr. Alexander ROKITANSKY, DrHC, is a general surgery, pediatric and adolescent surgery, pediatric intensive care medicine specialist, at Wiener Privatklinik hospital, talks about the state-of-the-art solutions for thoracic cavity malformations.
The deformation of the thorax leads to impaired cardiac output (limited filling of the heart by the reduced thoracic cavity) and impaired respiratory function. Both the heart and parts of the lungs cannot expand as naturally intended.
Depressions up to 2-3cm deep are classified as moderate, over 4cm as severe. Affected persons notice a rapid heartbeat and shortness of breath during physical exertion. The marked drop in physical performance is to be expected in the middle stage of life.
In many affected persons, the lower rib arches are also atypically bulging and protruding in the development of the funnel chest.
Combined deformities with keel and funnel formation, such as the Currarino Silverman syndrome, also occur frequently. In addition to all these somatic problems, there are also psychological problems that manifest themselves in significantly reduced self-esteem, including sometimes even auto-aggression.
The occasional opinion that this is a purely cosmetic problem has been clearly contradicted by medical and scientific results, just like the opinion that the deformity will “grow” into a normal body shape. Therefore, an early visit to the doctor is recommended around the age of 6.
Therapy: The treatment of pectus excavatum consists of a conservative and a surgical approach.
Conservative and surgical treatment elements are favourably used in combination. Conservative treatment consists of strengthening the muscles of the back, abdomen, chest and shoulder girdle, as well as the use of a specially shaped suction bell, which lifts the funnel and at the same time exerts targeted pressure on the protruding parts of the rib cage (rib arches). This therapy is effective if it is started around the age of 10 after appropriate adjustment by a medical specialist, although starting the therapy later, during puberty, can also be very effective. Daily applications of about 2 hours are recommended. Within the first months of treatment, interrupting the therapy for more than 3 days as a result of “tissue memory” leads to failure. The special suction bell leads to a successive flattening (depth) of the funnel, which can also be almost permanent, so that surgical therapy can even be avoided in a number of cases. Another effect of the suction bell treatment is the flexibilisation or pre-stretching of the funnel towards a normal shape. Even if the conservative measures, if they are applied at an older age, do not succeed in completely balancing the funnel, the flexibilisation (open synchondrotic soft manubrium – corpus – sterni transition in adults) makes the supplementary surgical correction technically easier and less stressful.
The current Y-suction bell (Comp. SANAG, Austria), which simultaneously applies suction for funnel compensation and pressure to the bulging rib arches, is a brand new development. This has made it possible to expand and optimise the conservative therapy options in a meaningful way.
Surgical therapy is based on the principle of the minimally invasive correction method according to D. Nuss, which is extended by additional surgical steps (Rokitansky modifications) especially for older, larger or adult patients. Here, the funnel is compensated by one or two one-piece implat – steel – bars (PSI – Fa. Hofer-Medical) and the lifted sternum is held in its regular position. The implants are anchored “flexibly” in the thoracic musculature. Wire or constricting cords around the ribs, which can break and have a tissue irritating effects, are prohibited. It is essential to avoid metal-to-metal contact to avoid the metal abrasion that occurs with movement. Therefore, e.g. crossed implants that touch each other should be strictly avoided.
The other modifications are horizontal or oblique notching to straighten the curved sternum, thoracoscopic slit notching of the deformed rib cartilage, endo-perichondral cartilage segment resection if necessary and, if necessary, loosening of coarse short fibrous tracts in the mediastinum that pull the sternum inwards.
By the Rokitansky modifications and an implant lying time of at least 4 years, recurrences from the experience of about 800 funnel chest operations have fallen below 0.5%. Implant displacements requiring a repeat operation have not occurred.
The optimal age for surgery is around 14-17 years of age. Very rarely, high-grade funnel chest deformities are corrected around the age of 5-6. This is based on the experience that the lung tissue grows until the age of 8 and can use the space gained in the thorax for itself.
Rokitansky recommends a hospital stay of 4-5 days, which is beneficial for the healing process. Check-ups are after one week, after one month, and after two months the patient is released for sports. All common and sometimes unusual sports (skydiving, motocross acrobatics, etc.) are possible. For example, patients successfully participate in Ironman competitions with two metal implants in the chest.
Patient after extensive correction using several combined surgical methods; The result is additionally favored by athletic training.