Robert Kelly
432 statements · 3 topics · summaries given as host listed separately
Featured statements
A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
quote ·
Pectus Carinatum
Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum.
quote ·
Pectus Carinatum
What one will frequently see in Pex excavatum is that the depressed area of the chest is absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath and sucks in air, the xyphoid pulls back towards the spine.
quote ·
Pectus Excavatum
It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period.
quote ·
Pectus Excavatum
It's probably uh. Productive to have the patient stand first. Uh, if you have a mirror in the room, have the patient, uh, watch himself in the mirror, uh, and ask the patient to take several deep respirations and watch the motion of the chest with respiration
quote ·
Single Ventricle / HLHS
The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it.
quote ·
Single Ventricle / HLHS
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Robert's statements about Pectus Carinatum 121 statements
Open the Pectus Carinatum collection →
Chest Wall Deformities with Dr. Robert Kelly
Quotation
When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression.
Open
Statement
Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally not occurring at rest but with exertion.
Open
Statement
Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.
Open
Quotation
It's probably uh. Productive to have the patient stand first. Uh, if you have a mirror in the room, have the patient, uh, watch himself in the mirror, uh, and ask the patient to take several deep respirations and watch the motion of the chest with respiration
Open
Statement
In a normal chest, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner).
Open
Quotation
The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
Open
Statement
In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath the xyphoid pulls back towards the spine.
Open
Statement
In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.
Open
Statement
When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first.
Open
Statement
In the multi-center study of pectus excavatum at 11 centers, roughly 2/3 of patients had symptoms of easy fatigability, shortness of breath, or chest pain.
Open
Statement
The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine; an index greater than 3.25 indicates severe pectus excavatum.
Open
Statement
The Kansas City group recognized that in a patient with a barrel chest, the Haller index underestimates the depth of the depression because the AP diameter is increased, and they advocate an alternative index comparing the AP distance at the depression to the normal lateral chest.
Open
Statement
Mitral valve prolapse is present in about 14% of pectus excavatum patients, compared to about 1% in young patients generally.
Open
Statement
On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).
Open
Statement
Patients with pectus excavatum came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored through surgery.
Open
Statement
Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is seen in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.
Open
Statement
Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.
Open
Statement
Surgical indications for pectus excavatum include at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests <80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, and major psychosocial issues related to body image.
Open
Statement
The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty (ages 11-13 for girls, a year or two older for boys).
Open
Statement
Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.
Open
Statement
Some Asian groups, particularly in Korea (Dr. Park), operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.
Open
Quotation
It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period.
Open
Quotation
The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people.
Open
Statement
The hard part of pain management is not to relieve the pain, but to relieve the pain without obliterating consciousness, which requires feedback from the patient.
Open
Quotation
We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it
Open
Statement
About half of pectus excavatum patients don't have their usual appetite after surgery, while about half eat very well.
Open
Statement
For the first month after pectus excavatum surgery, patients should only walk and do activities of daily life; beginning at 1 month they can liberalize physical activities; by 3-6 months they can do pretty much any activity except those where they know they'll get a blow to the chest.
Open
Quotation
I had a fellow who was a boxer who wanted to know if it was OK to go back to boxing. It's not OK to go back to boxing. We've just tried to make the chest very nice, and we don't want somebody pounding his fist into it.
Open
Statement
The Allergies test developed in Canada includes all components of the stainless steel bar, and patients have reacted against a number of minor components including nickel, chromium, and cobalt.
Open
Statement
Titanium bars must be bent at the factory and have to be ordered in advance; they are currently much more expensive than stainless steel bars.
Open
Statement
Measuring the bar length from mid-axillary line to mid-axillary line and subtracting an inch is one method that works very well.
Open
Quotation
I think it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation.
Open
Statement
It should be standard practice in patients with any difficulty in visualization to use some technique of sternal elevation during Nuss procedure.
Open
Quotation
The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it.
Open
Statement
The most important part of the Nuss procedure, whatever techniques are used, is that the surgeon sees the tip of the introducer at all times—not just knowing it's in there somewhere, but actually seeing it—to minimize the likelihood of injuring the heart.
Open
Statement
The bar must be positioned medial to the pectus ridge so there is a rib providing counterforce; if placed very laterally, only the intercostal muscles prevent movement and they will strip or rip under the load.
Open
Quotation
If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right.
Open
Statement
In patients who are growing, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so they are generally placed on only one side.
Open
Statement
If a patient is over approximately 6 feet 2 inches tall, the chances of needing two bars are almost 100%.
Open
Statement
In multiple series, short-term complications of the Nuss procedure are few and intervention has been infrequent.
Open
Statement
In a series of past 2000 Nuss procedures, about 2.7% of patients required some sort of revision for bar displacement.
Open
Statement
The incidence of bar displacement has been cut to about half (approximately 1.35%) by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.
Open
Statement
Most bar displacement now occurs due to some kind of marked force or trauma rather than spontaneous displacement.
Open
Statement
Bar allergy occurred in a little less than 1% (0.9%) of patients; screening for metal allergy has been performed since 2004 and has dramatically decreased the incidence.
Open
Statement
About 6.4% of pectus excavatum patients had clinical or patch test evidence of metal allergy.
Open
Statement
Wound infection occurred in 2.3% of patients, with more than 2/3 being superficial or cellulitis.
Open
Statement
Why recurrence happens after pectus excavatum surgery is still poorly understood; it can occur even when the bar is left in for 3 years.
Open
Statement
The bar should remain in place for at least 2 years before removal, with preference for closer to 3 years than 2 years.
Open
Statement
In a study from Saint Etienne, France published in Journal of Pediatric Surgery, vacuum bell treatment was effective in pretty much eliminating pectus excavatum in 23 of 73 patients.
Open
Statement
In patients who are young (under approximately 10 years old), the vacuum bell can be very effective in lifting the chest up.
Open
Statement
In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore movement of the chest wall, and patients will have some restrictive process from scarring.
Open
Statement
Brace therapy for pectus carinatum is successful somewhere between 2/3 and 3/4 of the time.
Open
Statement
Because any operation carries more morbidity than almost any brace, it's hard to say one shouldn't start with brace treatment for most patients with pectus carinatum.
Open
Quotation
I had a patient who was from the juvenile detention home. He had various behavioral problems, and he looked me in the eye and said, I'm not going to wear that thing. And I said, I believe you.
Open
Statement
Marcello Ferro's dynamic compression system brace solved two patient objections: it is comfortable (pressure can be adjusted) and it's concealable under even an opaque close-fitting t-shirt.
Open
Statement
Most patients with pectus carinatum do not have symptoms, but there is a small subset who complain of pain and exercise limitation who should be considered for operation.
Open
Statement
The reverse Nuss operation (Abramson procedure) works well in pectus carinatum patients with a flexible chest.
Open
Statement
There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.
Open
Statement
There is a family tendency in pectus deformities in approximately 40% of patients, but the majority still don't have a family history.
Open
Chest Wall Deformities with Dr. Robert Kelly
Quotation
When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression.
Open
Statement
Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest.
Open
Statement
Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.
Open
Quotation
A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
Open
Statement
In patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration.
Open
Statement
In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath.
Open
Quotation
What one will frequently see in Pex excavatum is that the depressed area of the chest is absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath and sucks in air, the xyphoid pulls back towards the spine.
Open
Quotation
In our series of patients, uh, at this point we've evaluated more than 4000 people for pectus excavatum, and just over 25% of them have had scoliosis.
Open
Statement
In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.
Open
Statement
When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon.
Open
Statement
In the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain.
Open
Statement
The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus.
Open
Statement
Mitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population.
Open
Statement
On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).
Open
Statement
In both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery.
Open
Statement
Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.
Open
Statement
Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.
Open
Statement
Dr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image.
Open
Statement
Around the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct.
Open
Statement
The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that.
Open
Statement
Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.
Open
Quotation
It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period.
Open
Quotation
The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people.
Open
Statement
Dr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback.
Open
Quotation
We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it.
Open
Statement
Dr. Kelly's center has not used epidurals for pectus excavatum surgery for several years.
Open
Statement
Postoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery.
Open
Statement
For the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest.
Open
Statement
The Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance.
Open
Statement
Titanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate.
Open
Statement
For Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other.
Open
Quotation
At this point it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation.
Open
Statement
Sternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify.
Open
Statement
The most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low.
Open
Quotation
The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it.
Open
Statement
To prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib.
Open
Statement
For Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus.
Open
Statement
In post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient.
Open
Quotation
If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right.
Open
Statement
The bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load.
Open
Quotation
In patients who are growing, the stabilizers, which will be encased by scar can cause a wasp waste effect if they're put on both sides. So we generally favor putting them on only one side of the bar.
Open
Statement
In growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar.
Open
Statement
Patients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation.
Open
Statement
The Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities.
Open
Statement
Postoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines.
Open
Statement
In Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.
Open
Statement
Most bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents.
Open
Statement
Bar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy.
Open
Statement
Wound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle.
Open
Statement
Recurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years.
Open
Statement
Dr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal.
Open
Statement
Dr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up.
Open
Statement
In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial.
Open
Statement
Because brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients.
Open
Quotation
Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum.
Open
Statement
Dr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands.
Open
Statement
Candidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing.
Open
Statement
The reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest.
Open
Statement
There is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history.
Open
Robert's statements about Pectus Excavatum 64 statements
Open the Pectus Excavatum collection →
Chest Wall Deformities with Dr. Robert Kelly
Quotation
When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression.
Open
Statement
Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest.
Open
Statement
Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.
Open
Quotation
A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
Open
Statement
In patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration.
Open
Statement
In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath.
Open
Quotation
What one will frequently see in Pex excavatum is that the depressed area of the chest is absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath and sucks in air, the xyphoid pulls back towards the spine.
Open
Statement
In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.
Open
Quotation
In our series of patients, uh, at this point we've evaluated more than 4000 people for pectus excavatum, and just over 25% of them have had scoliosis.
Open
Statement
When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon.
Open
Statement
In the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain.
Open
Statement
The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus.
Open
Statement
The Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant.
Open
Statement
Mitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population.
Open
Statement
On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).
Open
Statement
In both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery.
Open
Statement
Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.
Open
Statement
Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.
Open
Statement
Dr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image.
Open
Statement
Around the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct.
Open
Statement
The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that.
Open
Statement
Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.
Open
Statement
Some Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.
Open
Quotation
It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period.
Open
Quotation
The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people.
Open
Statement
Dr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback.
Open
Quotation
We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it.
Open
Statement
Dr. Kelly's center has not used epidurals for pectus excavatum surgery for several years.
Open
Statement
Postoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery.
Open
Statement
For the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest.
Open
Statement
The Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance.
Open
Statement
Titanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate.
Open
Quotation
At this point it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation.
Open
Statement
For Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other.
Open
Statement
Sternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify.
Open
Statement
The most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low.
Open
Quotation
The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it.
Open
Statement
To prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib.
Open
Statement
For Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus.
Open
Statement
In post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient.
Open
Statement
The bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load.
Open
Quotation
If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right.
Open
Quotation
In patients who are growing, the stabilizers, which will be encased by scar can cause a wasp waste effect if they're put on both sides. So we generally favor putting them on only one side of the bar.
Open
Statement
In growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar.
Open
Statement
Patients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation.
Open
Statement
The Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities.
Open
Statement
Postoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines.
Open
Statement
In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent.
Open
Statement
In Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.
Open
Statement
Most bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents.
Open
Statement
Bar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy.
Open
Statement
Wound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle.
Open
Statement
Recurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years.
Open
Statement
Dr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal.
Open
Statement
The vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients.
Open
Statement
Dr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up.
Open
Statement
In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial.
Open
Quotation
Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum.
Open
Statement
Because brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients.
Open
Statement
Dr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands.
Open
Statement
Candidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing.
Open
Statement
The reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest.
Open
Statement
There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.
Open
Statement
There is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history.
Open
Robert's statements about Single Ventricle / HLHS 247 statements
Open the Single Ventricle / HLHS collection →
Chest Wall Deformities with Dr. Robert Kelly
Statement
Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally not occurring at rest but with exertion.
Open
Quotation
When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression.
Open
Quotation
When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression.
Open
Statement
Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally not occurring at rest but with exertion.
Open
Statement
Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.
Open
Statement
Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.
Open
Quotation
It's probably uh. Productive to have the patient stand first. Uh, if you have a mirror in the room, have the patient, uh, watch himself in the mirror, uh, and ask the patient to take several deep respirations and watch the motion of the chest with respiration
Open
Quotation
It's probably uh. Productive to have the patient stand first. Uh, if you have a mirror in the room, have the patient, uh, watch himself in the mirror, uh, and ask the patient to take several deep respirations and watch the motion of the chest with respiration
Open
Statement
In a normal chest, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner).
Open
Statement
In a normal chest, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner).
Open
Quotation
The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
Open
Quotation
The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
Open
Statement
In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath the xyphoid pulls back towards the spine.
Open
Statement
In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath the xyphoid pulls back towards the spine.
Open
Statement
In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.
Open
Statement
In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.
Open
Statement
When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first.
Open
Statement
When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first.
Open
Statement
In the multi-center study of pectus excavatum at 11 centers, roughly 2/3 of patients had symptoms of easy fatigability, shortness of breath, or chest pain.
Open
Statement
In the multi-center study of pectus excavatum at 11 centers, roughly 2/3 of patients had symptoms of easy fatigability, shortness of breath, or chest pain.
Open
Statement
The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine; an index greater than 3.25 indicates severe pectus excavatum.
Open
Statement
The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine; an index greater than 3.25 indicates severe pectus excavatum.
Open
Statement
The Kansas City group recognized that in a patient with a barrel chest, the Haller index underestimates the depth of the depression because the AP diameter is increased, and they advocate an alternative index comparing the AP distance at the depression to the normal lateral chest.
Open
Statement
The Kansas City group recognized that in a patient with a barrel chest, the Haller index underestimates the depth of the depression because the AP diameter is increased, and they advocate an alternative index comparing the AP distance at the depression to the normal lateral chest.
Open
Statement
Mitral valve prolapse is present in about 14% of pectus excavatum patients, compared to about 1% in young patients generally.
Open
Statement
Mitral valve prolapse is present in about 14% of pectus excavatum patients, compared to about 1% in young patients generally.
Open
Statement
On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).
Open
Statement
On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).
Open
Statement
Patients with pectus excavatum came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored through surgery.
Open
Statement
Patients with pectus excavatum came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored through surgery.
Open
Statement
Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is seen in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.
Open
Statement
Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is seen in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.
Open
Statement
Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.
Open
Statement
Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.
Open
Statement
Surgical indications for pectus excavatum include at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests <80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, and major psychosocial issues related to body image.
Open
Statement
Surgical indications for pectus excavatum include at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests <80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, and major psychosocial issues related to body image.
Open
Statement
The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty (ages 11-13 for girls, a year or two older for boys).
Open
Statement
The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty (ages 11-13 for girls, a year or two older for boys).
Open
Statement
Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.
Open
Statement
Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.
Open
Statement
Some Asian groups, particularly in Korea (Dr. Park), operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.
Open
Statement
Some Asian groups, particularly in Korea (Dr. Park), operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.
Open
Quotation
It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period.
Open
Quotation
It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period.
Open
Statement
The hard part of pain management is not to relieve the pain, but to relieve the pain without obliterating consciousness, which requires feedback from the patient.
Open
Statement
The hard part of pain management is not to relieve the pain, but to relieve the pain without obliterating consciousness, which requires feedback from the patient.
Open
Quotation
The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people.
Open
Quotation
The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people.
Open
Quotation
We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it
Open
Quotation
We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it
Open
Statement
About half of pectus excavatum patients don't have their usual appetite after surgery, while about half eat very well.
Open
Statement
About half of pectus excavatum patients don't have their usual appetite after surgery, while about half eat very well.
Open
Statement
For the first month after pectus excavatum surgery, patients should only walk and do activities of daily life; beginning at 1 month they can liberalize physical activities; by 3-6 months they can do pretty much any activity except those where they know they'll get a blow to the chest.
Open
Statement
For the first month after pectus excavatum surgery, patients should only walk and do activities of daily life; beginning at 1 month they can liberalize physical activities; by 3-6 months they can do pretty much any activity except those where they know they'll get a blow to the chest.
Open
Quotation
I had a fellow who was a boxer who wanted to know if it was OK to go back to boxing. It's not OK to go back to boxing. We've just tried to make the chest very nice, and we don't want somebody pounding his fist into it.
Open
Quotation
I had a fellow who was a boxer who wanted to know if it was OK to go back to boxing. It's not OK to go back to boxing. We've just tried to make the chest very nice, and we don't want somebody pounding his fist into it.
Open
Statement
The Allergies test developed in Canada includes all components of the stainless steel bar, and patients have reacted against a number of minor components including nickel, chromium, and cobalt.
Open
Statement
The Allergies test developed in Canada includes all components of the stainless steel bar, and patients have reacted against a number of minor components including nickel, chromium, and cobalt.
Open
Statement
Titanium bars must be bent at the factory and have to be ordered in advance; they are currently much more expensive than stainless steel bars.
Open
Statement
Titanium bars must be bent at the factory and have to be ordered in advance; they are currently much more expensive than stainless steel bars.
Open
Statement
Measuring the bar length from mid-axillary line to mid-axillary line and subtracting an inch is one method that works very well.
Open
Statement
Measuring the bar length from mid-axillary line to mid-axillary line and subtracting an inch is one method that works very well.
Open
Statement
It should be standard practice in patients with any difficulty in visualization to use some technique of sternal elevation during Nuss procedure.
Open
Quotation
I think it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation.
Open
Statement
It should be standard practice in patients with any difficulty in visualization to use some technique of sternal elevation during Nuss procedure.
Open
Quotation
I think it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation.
Open
Statement
The most important part of the Nuss procedure, whatever techniques are used, is that the surgeon sees the tip of the introducer at all times—not just knowing it's in there somewhere, but actually seeing it—to minimize the likelihood of injuring the heart.
Open
Quotation
The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it.
Open
Statement
The most important part of the Nuss procedure, whatever techniques are used, is that the surgeon sees the tip of the introducer at all times—not just knowing it's in there somewhere, but actually seeing it—to minimize the likelihood of injuring the heart.
Open
Quotation
The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it.
Open
Quotation
If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right.
Open
Quotation
If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right.
Open
Statement
The bar must be positioned medial to the pectus ridge so there is a rib providing counterforce; if placed very laterally, only the intercostal muscles prevent movement and they will strip or rip under the load.
Open
Statement
The bar must be positioned medial to the pectus ridge so there is a rib providing counterforce; if placed very laterally, only the intercostal muscles prevent movement and they will strip or rip under the load.
Open
Statement
In patients who are growing, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so they are generally placed on only one side.
Open
Statement
In patients who are growing, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so they are generally placed on only one side.
Open
Statement
If a patient is over approximately 6 feet 2 inches tall, the chances of needing two bars are almost 100%.
Open
Statement
If a patient is over approximately 6 feet 2 inches tall, the chances of needing two bars are almost 100%.
Open
Statement
In multiple series, short-term complications of the Nuss procedure are few and intervention has been infrequent.
Open
Statement
In multiple series, short-term complications of the Nuss procedure are few and intervention has been infrequent.
Open
Statement
In a series of past 2000 Nuss procedures, about 2.7% of patients required some sort of revision for bar displacement.
Open
Statement
In a series of past 2000 Nuss procedures, about 2.7% of patients required some sort of revision for bar displacement.
Open
Statement
The incidence of bar displacement has been cut to about half (approximately 1.35%) by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.
Open
Statement
The incidence of bar displacement has been cut to about half (approximately 1.35%) by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.
Open
Statement
Most bar displacement now occurs due to some kind of marked force or trauma rather than spontaneous displacement.
Open
Statement
Most bar displacement now occurs due to some kind of marked force or trauma rather than spontaneous displacement.
Open
Statement
Bar allergy occurred in a little less than 1% (0.9%) of patients; screening for metal allergy has been performed since 2004 and has dramatically decreased the incidence.
Open
Statement
Bar allergy occurred in a little less than 1% (0.9%) of patients; screening for metal allergy has been performed since 2004 and has dramatically decreased the incidence.
Open
Statement
About 6.4% of pectus excavatum patients had clinical or patch test evidence of metal allergy.
Open
Statement
About 6.4% of pectus excavatum patients had clinical or patch test evidence of metal allergy.
Open
Statement
Wound infection occurred in 2.3% of patients, with more than 2/3 being superficial or cellulitis.
Open
Statement
Wound infection occurred in 2.3% of patients, with more than 2/3 being superficial or cellulitis.
Open
Statement
Why recurrence happens after pectus excavatum surgery is still poorly understood; it can occur even when the bar is left in for 3 years.
Open
Statement
Why recurrence happens after pectus excavatum surgery is still poorly understood; it can occur even when the bar is left in for 3 years.
Open
Statement
The bar should remain in place for at least 2 years before removal, with preference for closer to 3 years than 2 years.
Open
Statement
The bar should remain in place for at least 2 years before removal, with preference for closer to 3 years than 2 years.
Open
Statement
In a study from Saint Etienne, France published in Journal of Pediatric Surgery, vacuum bell treatment was effective in pretty much eliminating pectus excavatum in 23 of 73 patients.
Open
Statement
In a study from Saint Etienne, France published in Journal of Pediatric Surgery, vacuum bell treatment was effective in pretty much eliminating pectus excavatum in 23 of 73 patients.
Open
Statement
In patients who are young (under approximately 10 years old), the vacuum bell can be very effective in lifting the chest up.
Open
Statement
In patients who are young (under approximately 10 years old), the vacuum bell can be very effective in lifting the chest up.
Open
Statement
In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore movement of the chest wall, and patients will have some restrictive process from scarring.
Open
Statement
In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore movement of the chest wall, and patients will have some restrictive process from scarring.
Open
Statement
Brace therapy for pectus carinatum is successful somewhere between 2/3 and 3/4 of the time.
Open
Statement
Brace therapy for pectus carinatum is successful somewhere between 2/3 and 3/4 of the time.
Open
Statement
Because any operation carries more morbidity than almost any brace, it's hard to say one shouldn't start with brace treatment for most patients with pectus carinatum.
Open
Statement
Because any operation carries more morbidity than almost any brace, it's hard to say one shouldn't start with brace treatment for most patients with pectus carinatum.
Open
Quotation
I had a patient who was from the juvenile detention home. He had various behavioral problems, and he looked me in the eye and said, I'm not going to wear that thing. And I said, I believe you.
Open
Quotation
I had a patient who was from the juvenile detention home. He had various behavioral problems, and he looked me in the eye and said, I'm not going to wear that thing. And I said, I believe you.
Open
Statement
Marcello Ferro's dynamic compression system brace solved two patient objections: it is comfortable (pressure can be adjusted) and it's concealable under even an opaque close-fitting t-shirt.
Open
Statement
Marcello Ferro's dynamic compression system brace solved two patient objections: it is comfortable (pressure can be adjusted) and it's concealable under even an opaque close-fitting t-shirt.
Open
Statement
Most patients with pectus carinatum do not have symptoms, but there is a small subset who complain of pain and exercise limitation who should be considered for operation.
Open
Statement
Most patients with pectus carinatum do not have symptoms, but there is a small subset who complain of pain and exercise limitation who should be considered for operation.
Open
Statement
The reverse Nuss operation (Abramson procedure) works well in pectus carinatum patients with a flexible chest.
Open
Statement
The reverse Nuss operation (Abramson procedure) works well in pectus carinatum patients with a flexible chest.
Open
Statement
There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.
Open
Statement
There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.
Open
Statement
There is a family tendency in pectus deformities in approximately 40% of patients, but the majority still don't have a family history.
Open
Statement
There is a family tendency in pectus deformities in approximately 40% of patients, but the majority still don't have a family history.
Open
Chest Wall Deformities with Dr. Robert Kelly
Statement
Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest.
Open
Quotation
When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression.
Open
Statement
Common presenting symptoms of pectus excavatum are easy fatigability with exertion, shortness of breath with exertion, and chest pain in the area of the pectus depression, generally occurring with exertion rather than at rest.
Open
Quotation
When patients present, uh, commonly patients have symptoms, and those symptoms most frequently are easy fatigue ability with exertion, shortness of breath with exertion, and chest pain, commonly in the area of the pectus depression.
Open
Statement
Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.
Open
Statement
Both Marfan syndrome and Ehlers-Danlos syndrome are conditions for which pectus excavatum is a marker.
Open
Statement
In patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration.
Open
Quotation
A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
Open
Quotation
A patient with a normal chest should have, um, the ribs move like the handle of a bucket. So since they're attached at the front and, and the sternum and in the back at the spine, they would move up, up and out like the handle of a bucket does. The sternum should move normally like the handle of an old fashioned water pump, so it should move, uh, towards the ceiling and out towards the examiner.
Open
Statement
In patients with normal chest anatomy, ribs should move like the handle of a bucket (up and out) and the sternum should move like the handle of an old-fashioned water pump (towards the ceiling and out towards the examiner) during respiration.
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Quotation
What one will frequently see in Pex excavatum is that the depressed area of the chest is absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath and sucks in air, the xyphoid pulls back towards the spine.
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What one will frequently see in Pex excavatum is that the depressed area of the chest is absolutely fixed or in younger patients may move paradoxically, so that when the patient takes in a deep breath and sucks in air, the xyphoid pulls back towards the spine.
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In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath.
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In pectus excavatum, the depressed area of the chest is frequently absolutely fixed or in younger patients may move paradoxically, with the xiphoid pulling back towards the spine when the patient takes a deep breath.
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In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.
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In our series of patients, uh, at this point we've evaluated more than 4000 people for pectus excavatum, and just over 25% of them have had scoliosis.
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In a series of more than 4000 patients evaluated for pectus excavatum, just over 25% had scoliosis.
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In our series of patients, uh, at this point we've evaluated more than 4000 people for pectus excavatum, and just over 25% of them have had scoliosis.
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When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon.
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When both severe scoliosis (past 40 or 50 degrees requiring spinal procedure) and pectus excavatum are present, the more clinically disruptive problem should be addressed first, in consultation with the orthopedic surgeon.
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In the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain.
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In the multi-center study of pectus excavatum involving 11 centers, roughly two-thirds of patients had symptoms of easy fatigability, shortness of breath with exertion, or chest pain.
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The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus.
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The Haller index is the ratio of the inner transverse diameter divided by the distance between the back of the sternum and the front of the spine. Haller reported in 1987 that an index greater than 3.25 indicates severe pectus.
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The Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant.
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Mitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population.
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Mitral valve prolapse is present in about 14% of pectus excavatum patients in Dr. Kelly's series, compared to about 1% in young patients in the general population.
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On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).
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On average in a large number of pectus excavatum patients, pulmonary function tests are down by about one standard deviation from average (somewhere between 85 and 90% predicted).
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In both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery.
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In both Dr. Kelly's series and the multi-center study, patients came up by close to a standard deviation in pulmonary function when they had the bellows action of the chest restored by surgery.
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Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.
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Restrictive lung disease (FVC less than 80% predicted with normal FEV1/FVC ratio) is present in a significant fraction of pectus excavatum patients and is corrected by pectus operation, unlike asthma which is not corrected.
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Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.
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Patients with worse pectus excavatum have more likelihood of having restrictive pulmonary problems.
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Dr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image.
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Dr. Kelly's indications for pectus excavatum operation require at least 3 of 6 criteria: Haller index >3.2, pulmonary function tests decreased below 80% predicted, cardiac compression/mitral valve prolapse/other echo abnormalities, symptoms, progressive pectus, or major psychosocial issues related to body image.
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Around the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct.
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Around the time of the teenage growth spurt, there are many children in whom the pectus gets significantly deeper, and progressive deepening is considered a reason to intervene before it becomes more difficult to correct.
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The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that.
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The ideal age for pectus excavatum surgery is sometime just prior to the onset of puberty or early in puberty: in girls age 11 to 13, and in boys a year or two older than that.
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Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.
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Having the bar in place during the rapid growth spurt of puberty results in extremely low likelihood of recurrence if the bar remains until that process is completed or nearly completed.
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Some Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.
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It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period.
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It's really important to tell the patient and the parents that to move the chest from one position to another all at one time is painful, and that pain management has to be the top priority of the patient and the treating team in the immediate post-op period.
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The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people.
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The hard part is not to relieve the pain, but to relieve the pain without obliterating consciousness and that that requires feedback from the patient because it's a common perception that there's there's different pain thresholds for different people.
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Dr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback.
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Dr. Kelly's center uses patient-controlled analgesia (PCA) pumps with a steady background dose of narcotic and ability to give booster doses, emphasizing the need to dial in the correct dose on the night of surgery based on patient feedback.
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We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it.
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We'll start you out on a dose that's been good for a lot of people, uh, with a similar problem before you, but if you aren't getting enough pain medicine, you need to tell the nurse because you're the only one who knows, uh, and we can generally fix it if we know about it.
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Dr. Kelly's center has not used epidurals for pectus excavatum surgery for several years.
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Dr. Kelly's center has not used epidurals for pectus excavatum surgery for several years.
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Postoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery.
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Postoperative recommendations include spirometry hourly when awake, walking beginning the day after operation (emphasizing frequency over distance), eating small amounts (a couple hundred calories) every couple hours if appetite is reduced, and not rushing recovery.
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For the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest.
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For the first month after pectus excavatum surgery, patients should only walk and perform activities of daily living. Beginning at 1 month they can liberalize physical activities, and by 3 to 6 months can do almost any activity except those where they know they will get a blow to the chest.
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The Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance.
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The Allergies test developed in Canada includes all components of the stainless steel bar and is used for preoperative metal allergy screening. Patients who react (most commonly to nickel, but also chromium, cobalt, and other components) can receive a titanium bar, which must be bent at the factory and ordered in advance.
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Titanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate.
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Titanium bars are currently much more expensive than stainless steel bars. In an era of responsible cost containment, if stainless steel works well and costs less, it should be used when appropriate.
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At this point it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation.
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For Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other.
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For Nuss procedure, thoracoscopy should be standard practice in patients with any difficulty in visualization, to ensure the tip of the introducer is seen at all times when passing from one side to the other.
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At this point it really should be standard practice, uh, uh, in patients with anything more than with any difficulty in visualization at all to use some technique of sternal elevation.
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Sternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify.
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Sternal elevation techniques (vacuum bell, subxiphoid finger or bone hook, or Rultract device) are really important for Nuss procedure to improve visualization and make the path from one side to the other easier to identify.
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The most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low.
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The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it.
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The most important part of the Nuss procedure is seeing the tip of the introducer at all times when passing from one side to the other. If this is done, the likelihood of injuring the heart is exceedingly low.
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The, the most important part of the case, whether whatever techniques you use is that you see the tip of the introducer at all times, and that means you really have to see it. You can't say, well, it's in there somewhere. You have to see it.
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To prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib.
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To prevent bar displacement in Nuss procedure, Dr. Kelly favors using a tongue-in-groove stabilizer on one end of the bar and wrapping around the bar and adjacent rib with heavy absorbable suture (number 1 PDS), commonly putting 4 thicknesses around the intersection of bar and rib.
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For Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus.
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For Nuss procedure incisions, measure from mid-axillary line to mid-axillary line and subtract an inch to determine bar length. Make 2-3 cm incisions more or less from anterior to mid-axillary line at the cephalocaudad level of the deepest point of the pectus.
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In post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient.
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In post-pubertal girls, making an incision where the breast meets the chest wall in a curved incision along the line of the breast gives excellent access and is a little more medial than the standard incision, which can be more convenient.
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The bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load.
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If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right.
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If you put the bar in very laterally, the slope of the ribs is such that the only thing preventing movement is the intercostal muscles, and they won't bear that kind of load. They'll strip, they'll rip. Um, ask me how I know that, right.
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The bar should rest medial to the pectus ridge so there is a rib providing counterforce anteriorly on each side while the sternum pushes posteriorly. If placed very laterally, only intercostal muscles prevent movement and they will strip or rip under the load.
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In patients who are growing, the stabilizers, which will be encased by scar can cause a wasp waste effect if they're put on both sides. So we generally favor putting them on only one side of the bar.
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In growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar.
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In growing patients, stabilizers on both sides of the bar can cause a wasp-waist effect when encased by scar, so Dr. Kelly generally favors putting stabilizers on only one side of the bar.
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In patients who are growing, the stabilizers, which will be encased by scar can cause a wasp waste effect if they're put on both sides. So we generally favor putting them on only one side of the bar.
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Patients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation.
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Patients over approximately 6 feet 2 inches tall have almost 100% chance of needing two bars for Nuss procedure. For shorter patients, the decision depends on how the sternum came up at operation.
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The Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities.
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The Chestwall International Group will be meeting June 15-17, 2016 in Norfolk, Virginia with participants from around the world presenting on various aspects of chest wall deformities.
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Postoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines.
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Postoperatively for Nuss procedure, Dr. Kelly's center tries to wean patients off the PCA pump by stopping the basal rate on the second day and stopping the PCA altogether on the third day, so by the third day patients are on all oral medicines.
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In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent.
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In Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.
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In Dr. Kelly's series of past 2000 Nuss procedures, about 2.7% of patients have required some sort of revision for bar displacement. This incidence has been cut to about half by using stabilizers and wrapping around the crossing of the bar to the rib with pericostal sutures.
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Most bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents.
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Most bar displacement in Dr. Kelly's current experience involves some kind of marked force, such as trauma from accidents.
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Bar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy.
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Bar allergy occurred in a little less than 1% (0.9%) of patients. Since screening for metal allergy began in 2004, this has dramatically decreased the incidence. About 6.4% of patients had clinical or patch test evidence of metal allergy.
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Wound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle.
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Wound infection occurred in 2.3% of patients in Dr. Kelly's series, with more than two-thirds being superficial or cellulitis. The center emphasizes skin preparation and perioperative antibiotics using an infection prevention bundle.
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Recurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years.
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Recurrence after Nuss procedure occurred in about 1.2% of patients in Dr. Kelly's series. Why recurrence happens is still poorly understood, even when bars are left in for 3 years.
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Dr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal.
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Dr. Kelly's center tries to see patients at 6 months after operation and then organize when bar removal will be. They favor removing the bar closer to 3 years than to 2 years, but it needs to be at least 2 years before removal.
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The vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients.
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Dr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up.
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Dr. Kelly's center has been using the vacuum bell for about 2 years and believes that in patients who are young (under about 10 years old), the vacuum bell can be very effective in lifting the chest up.
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In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial.
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In patients with recurrent pectus excavatum following a previous Ravitch operation, a Nuss procedure can elevate the chest to some extent but won't restore chest wall movement, and patients will have some restrictive process from scarring. In some of these patients, a Ravitch operation may be beneficial.
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Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum.
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Because brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients.
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Quotation
Because brace therapy has been demonstrated in a lot of places to be so successful, so somewhere between 2/3 and 3/4 of patients are are cured with the brace and because any operation carries more morbidity than almost any brace, I, I think it's, it's hard to say you shouldn't start with a, with a brace treatment for most patients with pectus carinatum.
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Because brace therapy for pectus carinatum has been demonstrated to be successful in many places (somewhere between two-thirds and three-quarters of patients are cured), and any operation carries more morbidity than almost any brace, it is hard to justify not starting with brace treatment for most patients.
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Dr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands.
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Dr. Kelly's center generally uses Marcello Ferro's dynamic compression system for pectus carinatum. The brace solved two patient objections: it is comfortable (pressure can be adjusted) and concealable (not visible under an opaque t-shirt). It works approximately three-quarters of the time in their hands.
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Candidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing.
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Candidates for surgical treatment of pectus carinatum include patients who fail brace therapy, those with significant symptoms (pain and exercise limitation, though most carinatum patients do not have symptoms), and those whose chest is very stiff and not making progress with bracing.
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The reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest.
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The reverse Nuss operation (Abramson procedure) for pectus carinatum involves placing a bar in front of the sternum to pull it back. Dr. Kelly's center has used this operation since 2008 and it works well in patients with a flexible chest.
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There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.
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There is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history.
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There is a family tendency for chest wall deformities in approximately 40% of patients, but the majority still don't have a family history.
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Summaries Robert gave as host · 10 summaries
Recaps of other experts' statements, not Robert's own clinical position.
Summaries Robert gave as host · Pectus Carinatum 5 summaries
Open the Pectus Carinatum collection →
Chest Wall Deformities with Dr. Robert Kelly
Host summary
Robert Kelly summarizing a resource: The Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant.
Open
Host summary
Robert Kelly summarizing a resource: Some Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.
Open
Host summary
Robert Kelly summarizing a resource: In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent.
Open
Host summary
Robert Kelly summarizing a resource: The vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients.
Open
Host summary
Robert Kelly summarizing a resource: There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.
Open
Summaries Robert gave as host · Single Ventricle / HLHS 5 summaries
Open the Single Ventricle / HLHS collection →
Chest Wall Deformities with Dr. Robert Kelly
Host summary
Robert Kelly summarizing a resource: The Kansas City group recognized that in patients with a barrel chest, the Haller index underestimates the depth of depression because the AP diameter is increased. They advocate an alternative index comparing the depth at the depression to the depth more laterally, with more than 10% drop considered significant.
Open
Host summary
Robert Kelly summarizing a resource: Some Asian groups, particularly Dr. Park in Korea, operate on pectus excavatum patients when they are quite young (well under 10 years old) and report good results.
Open
Host summary
Robert Kelly summarizing a resource: In multiple series of Nuss procedures, short-term complications are few and intervention has been infrequent.
Open
Host summary
Robert Kelly summarizing a resource: The vacuum bell treatment for pectus excavatum was developed by Kloby in Germany. A recent paper from a hospital in Saint-Etienne, France published in Journal of Pediatric Surgery found it effective in eliminating pectus excavatum in 23 of 73 patients.
Open
Host summary
Robert Kelly summarizing a resource: There is a broad perception among surgeons who have done many Ravitch operations for carinatum that there is an extremely low recurrence rate after that procedure, as opposed to the 10% recurrence rate after excavatum Ravitch.
Open