Current Management of Pectus Deformities. George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children s Mercy Hospital Kansas City, Missouri

Transcription

1 Current Management of Pectus Deformities George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children s Mercy Hospital Kansas City, Missouri

2 Pectus Deformities Pectus Excavatum Pectus Carinatum Mixed Excavatum/Carinatum

3 What Are Your Criteria for 1. Symptoms only 2. Symptoms and Haller Index > Symptoms and Haller Index > 4.0 Repair? 4. Haller Index > 4.0 with/without symptoms

4 Do You Test Your Patients Undergoing Repair For a Nickel Allergy -? 1. Always, every patient undergoes testing for nickel allergy 2. Sometimes, depends on answers to questions about nickel and metal allergies 3. Never had this problem so don t test

5 Once You Have Decided on Repair, Which Technique Do You Use? 1. Open repair (Ravitch) 2. Minimally invasive repair (Nuss) 3. Other

6 How Do You Try to Prevent Infection With The Nuss Repair -? 1. Nothing special prep carefully 2. Prep twice 3. IV antibiotics 1 pre-op dose 4. IV antibiotics 1 pre-op dose and for 24 hours postoperatively 5. IV antibiotics 1 pre-op dose and for 2 postoperative days or longer 6. Double glove 7. Ioban drape over sterile field

7 Prep and Drape

8 How Do You Avoid Cardiac Injury With the Nuss Procedure -? 1. Slow, careful technique; no special aids 2. Thoracoscopy sometimes, depending on the severity 3. Thoracoscopy always left side 4. Thoracoscopy always right side 5. Thoracoscopy always both sides 6. Sub-xiphoid incision no thoracoscopy 7. Other?

9 Repair Pectus Excavatum Using a Sub-xiphoid Incision

10 How Do You Manage Post- Operative Pain? 1. PCA (Patient Controlled Analgesia) always 2. Epidural always 3. Intercostal block 4. Infusion via catheter in thoracic cavity 5. Other

11 Epidural vs PCA 110 patients randomized Epidural group: longer OR time, more phone calls to anesthesia, greater hospital charges Pain scores favored epidural group first 2 days, then favored PCA last 2 days Epidural catheter was removed w/in 24 hours or could not be placed in 22% of the epidural patients

12 Post-Operative Management Management of post-operative infections can be difficult infections ( 168 pts) 5 underwent I & D Recurrent infx 3/6; one had bar removal early

13 What Do You Do about Rib-flaring That Develops Postoperatively? 1. Nothing 2. Use a binder 3. Excise costal margin before remove bar 4. Excise costal margin at time of bar removal

14 How long do you leave the bar? 1. 1 year 2. 2 years 3. 3 years 4. 4 years

15 How long do you leave the bar? patients (Nickel allergy - 2.8%)

16 Results Better if Bar Left > 24 Months

17 Experience Sub-xiphoid Incision Two bars Infection Children s Mercy Kansas City (December 1999 October patients) December 1999 March patients Stabilizer discomfort/dislodgement requiring removal Bar rotation PTX req. chest tube Recurrence requiring reoperation Cardiac injury Mean hospitalization J Pediatr Surg 45: , 2010

18 New Techniques 3 MP Magnetic Mini-Mover Procedure Vacuum Cup Suction

19 Magnetic Mini-Mover Anterior plate containing magnet Threaded post

20 Implanted Magnet and External Brace

21 Pectus Carinatum Chondrogladiolar (Lower) Chondromanubrial (Upper) (Currarino Silverman Syndrome)

22 How Do You Manage the Teenager With the Mild Moderate Pectus Carinatum (Chondrogladiolar type)? 1. Nothing continued observation 2. Bracing 3. Open repair (Ravitch procedure) 4. Minimally invasive repair (Abramson procedure)

23 How Do You Manage the Teenager With A Severe Pectus Carinatum (Chondrogladiolar type)? 1. Nothing continued observation 2. Bracing 3. Open repair (Ravitch procedure) 4. Minimally invasive repair (Abramson procedure)

24 If You Brace, Do You Use: 1. Brace made in your hospital or city? 2. Dynamic compression brace made by Dr. Martinez-Ferro and colleagues?

25 Dynamic Compression Bracing Initial chest measurements for a custom fit brace Pressure for Initial Correction (PIC) Gives a measurement of pressure, in pounds per square inch (psi), necessary to correct the carinatum Brace is only indicated if PIC < 7.5 psi

26 Pressure of Treatment POT

27 Dynamic Compression Device Treatment Plan Recommend wearing the brace for 23 hours per day Duration of treatment is variable (6 20 months) Follow-up appointment 1 month after initial fitting, then every 1 3 months After chest remodeling is achieved, it is recommended the brace is still worn in retainer mode

28 Currarino Silverman Syndrome

29 Abramson Procedure (MIS Repair Pectus Carinatum)

30 Mixed Defects Management Options -?

31 QUESTIONS