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Funnel chest (pectus excavatum)
Minimally invasive surgery for pectus excavatum
Minimally invasive surgery for pectus excavatum has evolved over the decades, with various surgical methods developing since the most classical NUSS procedure introduced by Donald Nuss in the 1990s. His basic surgical process involves administering general anesthesia to the patient, who is then laid flat on the operating table. A horizontal line is drawn from the deepest part of the depression to the armpit, where one to two small incisions are made under the armpit. The skin is then freed to access the chest cavity, and a steel plate is gradually inserted behind the sternum at its deepest point, after which the depressed sternum is elevated by flipping the plate. Of course, there have been improvements to the NUSS procedure, such as the modified Nuss procedure that reduces the flipping process, thus minimizing the impact and damage to the bones. For instance, ultra-minimally invasive surgeries, which require only a single-port incision, have evolved from the NUSS procedure by reducing or eliminating the need for flipping or an incision. Later, the Wang procedure involved placing the steel plate in front of the sternum, using the principle of a suspension bridge to elevate the depressed sternum. Thus, the evolution of surgery for pectus excavatum continues to advance, with the surgical processes improving, wounds becoming smaller, and the number of incisions decreasing.
Pectus excavatum heart hazards
Pectus excavatum can harm the patient's or child's heart, primarily manifesting in compression of the heart and affecting the function of the internal heart valves. Imagine a normal person's rib cage, which is oval in cross-section. There is a certain ratio between the lateral diameter and the anterior-posterior diameter, with normal individuals having a ratio of less than 2.5. However, in patients with pectus excavatum, this anterior-posterior diameter is significantly compressed, meaning the sternum moves closer to the spine, compressing inward and backward, squeezing the heart - this is the first step. The heart itself is a contractile muscular organ, its purpose being to eject blood and circulate it throughout the body. If the sternum and spine directly compress the heart, preventing it from fully expanding, then blood cannot fully flow back into the heart, and thus the ejection or pumping function of the heart will be impacted. Secondly, besides the heart being compressed, just like a house becoming deformed from being squeezed, the doors within the house cannot function properly; they cannot close or open well. Thus, pectus excavatum not only compresses the heart itself but also severely harms the function of the heart valves, even causing mitral valve prolapse in some patients.
Can people with funnel chest gain weight?
The majority of pectus excavatum cases encountered clinically are congenital thoracic deformities, which means the sternum in the middle of the chest is indented inward and backward. This inward and backward indentation can compress the lungs and the heart, especially in severe cases of pectus excavatum, causing significant compression to the lungs and heart. It prevents the heart from fully expanding, and might even push the entire heart into the left chest cavity, also preventing the lungs from effectively expanding. Therefore, children with this condition tend to have weaker constitutions, are prone to colds, and their ability to engage in physical activities like running is not as good as other children. Pectus excavatum generally affects the development of children, especially in severe cases. Mild pectus excavatum involves only a slight indentation and does not severely compress the heart, and children with such a condition can still gain weight if their nutrition is adequate. However, in severe cases of pectus excavatum, besides impacting the heart and lungs, it can also affect the patient's personality, self-confidence, and social interactions, potentially leading to insecurity, depression, and even suicidal tendencies.
Harm of pectus excavatum
The dangers of pectus excavatum can generally be divided into two aspects: one is the harm to the physiological functions of the patient, and the other is the psychological impact on the patient. The physiological harm can be further divided into two categories: one is the impact on lung function, and the other is the impact on heart function. We can imagine that in normal individuals, the sternum is positioned in front of the heart and lungs. However, in patients with pectus excavatum, due to congenital hereditary or genetic factors, the sternum is pushed backward towards the spine, compressing inward and backward, which causes the heart to be squeezed, deformed, and the lungs to be compressed, preventing them from fully expanding. Thus, both the heart and lungs of the patient are subjected to certain pressures, affecting both cardiac and pulmonary functions. In addition to the impact on cardiopulmonary function, the patient's thoracic cage is deformed. It appears as if the center of the chest has been punched in. This kind of deformed chest affects the patient's social abilities, including interactions with potential boyfriends or girlfriends. Imagine, for instance, removing one's shirt at the pool in summer, attracting stares as if one were a monster. Therefore, patients may lack confidence, especially in romantic and social interactions, and some may even experience certain levels of depression or suicidal tendencies.
Pectus excavatum is caused by what?
The specific etiology of pectus excavatum is not completely clear, but there are mainly two types of pectus excavatum: the simple type and the complex type, which means it is accompanied by other diseases. Currently, pectus excavatum is somewhat related to congenital genetic inheritance. This is because pectus excavatum is related to many connective tissue disorders, and many patients with congenital diaphragmatic hernias, psychogenic subglottic stenosis, and underdeveloped bronchopulmonary tissues also present with pectus excavatum. Although these diseases do not directly cause pectus excavatum, the reasons for the development of pectus excavatum, whether directly related to connective tissue disorders or not, are somewhat related to genetic factors. Therefore, it is currently considered that pectus excavatum is caused by genetic factors and inheritance.
How to treat pectus excavatum?
There are many treatment methods for pectus excavatum, and the choice depends on the severity of the pectus excavatum, the age and chest wall elasticity of the child with pectus excavatum, the potential for further growth and development, and the expectations of the patient and their family. For younger children with pectus excavatum, where the chest wall is more elastic and soft, and in cases of mild pectus excavatum, a pectus excavatum suction cup can be considered. This device uses a certain amount of pressure, similar to a car suction cup, which is commonly seen in auto repair shops where a dented plastic bumper is gradually pulled out using a suction cup. This principle is also utilized by the pectus excavatum suction cup. Of course, this is under the premise that the patient is younger and has a softer chest, making it easier to be corrected by suction. For older patients with a harder chest, using a suction cup might not be appropriate, and surgical treatment may need to be considered. There are several surgical techniques available, ranging from the early Ravitch procedure, which involves a sternotomy and complete detachment of the sternum followed by flipping it, to the later Nuss procedure, and up to the current Wang surgical method and minimally invasive techniques.
Is pectus excavatum scary?
Is pectus excavatum scary? In a normal person, the thoracic transverse diameter and anteroposterior diameter have a normal ratio. For example, in normal individuals, this ratio of the transverse diameter to the anteroposterior diameter is less than 2.5. However, some children, due to congenital or acquired reasons, may have a sternum that is concave inward in the middle. In such cases, the concavity of the sternum significantly reduces the anteroposterior diameter, and the ratio of the transverse to anteroposterior diameter then becomes greater than 2.5. For pectus excavatum where the ratio is between 2.5 and 3.5, we suggest conservative treatment or observation, and a pectus excavatum suction cup can be used. If the ratio is greater than 3.5, the pectus excavatum is very pronounced, and we recommend surgical treatment. In severe cases of pectus excavatum, where the ratio of the transverse to anteroposterior diameter is greater than 4, there are instances where the chest is almost touching the back, with only a few millimeters of space between the anterior chest wall and the spine during surgery. In such severe cases, the heart is completely pushed to the left side of the patient, significantly affecting both cardiac and pulmonary function, impacting the patient’s physical development. In severe cases, it can also cause significant psychological issues, including severe feelings of inferiority, lack of self-confidence, poor social skills, and even severe depression or suicidal tendencies. Therefore, severe pectus excavatum can indeed be quite frightening.
How to exercise the pectoral muscles with pectus excavatum?
How to exercise the pectoral muscles with pectus excavatum, we know that the indentation of pectus excavatum is concave inward and backward, that is, the front sternum in the middle of a person's chest compresses backward towards the spine. Exercising the pectoralis major muscle aims to lift the muscles on both sides of the sternum, but the attachment point of the pectoralis major actually pulls from the ribs outward and upward towards the humeral tuberosity of the arms. This type of lifting actually pulls the force of the ribs or a part of the sternum outward, and it cannot pull forward. Indeed, the forward force is the direction truly needed when correcting pectus excavatum. Therefore, patients with pectus excavatum can exercise the pectoralis major, do push-ups, and perform dumbbell fly exercises, which are all feasible. However, such exercise will only make the pectoral muscles thicker and the force is directed sideways, and it cannot effectively pull the downward and inward-concaved sternum forward. Therefore, although individuals with pectus excavatum can perform exercises like push-ups and dumbbell flies like normal individuals, these exercises should not be expected to significantly improve pectus excavatum. Moreover, current medical technology and trials have not found exercising the pectoralis major to have a substantial corrective effect on pectus excavatum.
What should be noted in daily life for people with funnel chest?
Since pectus excavatum is an inward and backward depression, such a depression may gradually become apparent even from a young age, especially worsening during adolescence. Therefore, children or patients with this condition should be aware of any significant lack of calcium or vitamin D. Of course, since pectus excavatum may also be somewhat related to familial genetic factors, it is important to check whether the child has any congenital heart diseases, Noonan syndrome, or connective tissue disorders. Since pectus excavatum causes an inward and backward indentation that compresses the heart and lungs, children with this condition may not be able to fully expand their lungs or completely relax their hearts. Consequently, these children tend to have a weaker constitution and may catch colds easily. Therefore, children with pectus excavatum should avoid crowded places, as their weaker constitution makes them more susceptible to colds, which can exacerbate their developmental issues, thus creating a vicious cycle.
Can people with funnel chest work?
Whether pectus excavatum can affect work depends on two aspects. Firstly, if it is a mild case of pectus excavatum, with an index less than 3.25, such mild conditions do not cause significant compression on the heart or lungs, and the patient will not have too many work-related issues. However, if the pectus excavatum index is greater than 3.25 and the chest is sunken inward and backward, significantly compressing the heart and lungs, such a condition prevents the heart from fully relaxing and the lungs from fully expanding, which can impact the patient's activities. Besides the physiological impact, this condition can also significantly affect social interactions, especially for young children or adults. Some patients may suffer severe inferiority complexes, depression, and even suicidal tendencies, which, of course, will also affect their work capability and state. Therefore, for severe cases of pectus excavatum, it is recommended to wait until after treatment to return to work. Once the pectus excavatum is corrected, and the heart and lung functions are no longer compressed, and the appearance is normalized, the patient's work capability should be completely fine.