Thursday, February 17, 2011

PECTUS EXCAVATUM MAY NOT BE LIFE-THREATENING UNLESS IN ITS MOST SEVERE FORM, BUT THE CONDITION IS NOT AN EASY ONE TO LIVE WITH. IT AFFECTS YOU PHYSICALLY, MENTALLY AND EMOTIONALLY.

More commonly known as ‘sunken chest’ or ‘funnel chest’, the condition afflicts one in about 1,000 births. Other names for it include ‘hollowed chest’ and ‘cobbler’s chest’. It is the most common type of congenital chest-wall abnormality, making up 90per cent of all cases, and is suspected to be familial—35 to45 per cent of cases have been reported within families.

It is also more dominant in males with a 3:1 male-to-female ratio. IN 2008, IJN marked a first by performing the Minimally Invasive Pectus Excavatum Repair (MIPER) or Nussprocedure (Donald Nuss, 1997) on two patients with Pectus Excavatum by Dr Jeswant Dillon, IJN Consultant Cardiothoracic Surgeon. 

Previously, the condition was treated with the Open Technique (Ravitch procedure, 1949) which was a difficult, complex open and invasive surgery. This procedure involved making a large, transverse sub-mammary chest incision, breaking the sternum, re-sectioning the costal cartilages and raising the pectoralis muscle flaps. The Open Technique operations are long. A procedure can take up to six hours and there is a high risk of blood loss. The patients have to stay in hospital for a considerable length of time and the post-operative pain is significant. The procedure also leaves a large, unsightly scar. While a scar may seem like the least of a patient’s problems, it is significant in these cases because many of those with the condition suffer from low self-esteem because of the way their chests look.

With the new procedure, the process is much simpler. The Nuss procedure is a minimally invasive surgical approach that inserts a customized stainless steel bracing bar into the chest cavity to brace and remodel the anterior chest wall. The operation has been used since1997 and has shown excellent results. It is based on the principle that the chest wall possesses remodeling and reconfiguration capabilities. The bar is left in place for two to three years (in children), or three to five (in adults). Once the chest wall is reconfigured, the bar can be removed in a simple outpatient procedure.

The operation does not have any side effects except for a small risk of displacement or infection. There is no rejection of the steel bar by the body. Most patients only need to insert one bar, but there are cases where two bars are needed. This happens when the depression of the chest is too long or too wide. Although the operation has been performed on toddlers aged 18 months and above, Dr Jeswant’s opinion the best time for someone to undergo the operation would be between the ages of eight and 13: This is so that when the growth spurt occurs, the chest does not sink in again.

Why has it taken so long for the procedure to come to our shores?
First there’s the demand. If there are a lot of people coming to us with a condition and it is a life threatening one, then it’s in demand. In the case of pectus excavatum, people were not referred before because the surgery was a long and complicated one. So they would only opt for surgery when it was life-threatening.

We do hope that, since this procedure is now readily available, more people will come for the procedure—while it may not be life threatening, it does have psychological effects that affect a patient’s lifestyle and confidence. The best thing about the procedure is that patients can be up and about again within two weeks. They can start competitive sports again in two to three months, and contact sports in six months.

Sunken Chest


According to Dr Jeswant Dillon, the depressed anterior chest wall can cause compression on the heart and lungs. In terms of the heart, it brings about lateral displacement (and compression) of the heart, producing right ventricular filling problems.




What is it?
Pectus excavatum is a progressive chest deformity that causes a depression (posterior displacement) of the sternum and anterior chest wall. This results in a caved-in or sunken appearance of the anterior chest wall or a concave “funnel shaped” chest.
According to Dr Jeswant Dillon, IJN’s Consultant Cardiothoracic Surgeon, the condition tends to progress with age: “It is usually present at birth but becomes most marked and worsens during puberty due to rapid bone growth during the teenage growth spurt,” he says.

What causes it?
Unfortunately, there are no known causes of the condition. It is still poorly understood and is only known as a mal-development of the anterior chest wall. There may be some association with Marfan’s syndrome (10 per cent of cases have Marfan’s) and many are Marfanoid with hyper flexibility of cartilage. It has also been associated with the Ehlers-Danlos and Poland syndromes.

What are the effects on the body?
According to Dr Jeswant, the depressed anterior chest wall can cause compression on the heart and lungs. In terms of the heart, it brings about lateral displacement (and compression) of the heart, producing right ventricular filling problems. The decreased flexibility of the chest wall and compression of the lungs affect respiratory functions causing restrictive respiratory dysfunction. “Compression can also cause restricted organ growth,” he says.

Diagnostic tests
Dr Jeswant says that there are a few ways to diagnose the condition.
These are:
  • Chest x-ray: Shows angulation of the sternum; bone and cartilage deformity.
  • CT-scan: Reveals cardiac displacement and sometimes compression. It also calculates Haller’s index of severity of pectus. A Haller’s index of more than 3.25 indicates severe pectus deformity.
  • Pulmonary function test: Those suffering from the condition often demonstrate values less than 80 per cent of a normal individual
  • ECG: Arrhythmia may be present
  • Echocardiogram: A person may encounter filling impairment of the right ventricle especially when in an upright position.  There is often the presence of a mitral valve prolapse.

When you should opt for surgery
Not everyone is physically impaired by the condition, but when you do have some symptoms, it may be time to think about surgery. Some of the signals that you can look out for are:

A. Functional impairment
This is when there is a reduction in the amount of exercise that you can do, or if you have a drop in endurance. Dr Jeswant explains that some people become easily fatigued, have chest pains, back pains, arrhythmia or recurrent respiratory infections (pneumonia).

B. Psychological impairment
One of the more harming effects of the condition, says Dr Jeswant, are the psychological effects: “Many have poor self-perception. They withdraw from society and avoid any activity that exposes the chest.” This is a very real problem especially for adolescents who are looking for their own space in society.

C. Haller index (on chest X-ray or CT-scan)
Dr Jeswant adds that if a patient presents a Haller index of more than 3.25, this denotes clinical severe deformity and the patient should undergo corrective surgery.

10 comments:

  1. how much is the cost for a surgery here in malaysia?

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  2. I also want to know how much it cost. Any prompt reply woulb be appreciated.

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    1. Anyone know how to contact for help. My contact number is 0169030354.

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  3. Hello SIR!, How to make my chest up without surgery..I Also having pectus excavatum..I really want change my chest..please!

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  4. I also want to know how much it cost. Any prompt reply would be appreciated. My contact number is 0169030354.

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  5. Good evening. My son who is 16 yrs old has the above PE condition. Is it possible for me to bring my son to IJN for checkup? If possible, which doctor should I contact?

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  6. i want to know too please feel free to whatsaap me +6598693667 or email me yeechaizz@gmail.com

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  7. Wassalam.. how much the cost of surgery ??? Please respon doctor. I had PE in person and in hopes can fix

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    1. This comment has been removed by the author.

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  8. Aslm,i aslo have pectus carinatum its still same like pectus excavatum but without surgery have another idea like chest brace.

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