Dr. Kelly,

Thank you so much for such a wonderful podcast and review of the management of Pectus! I have a few questions that weren't addressed:

What do you do for patients who don't want surgery? I have a handful of patients with moderate to severe depressions and minor symptoms (mainly intermittent chest pain and respiratory fatigue with exertion) who do not want surgery. They are not heavy into exercise or sports and the depression doesn't bother them enough psycho-socially to pursue surgical intervention. I counsel them regarding the low risk of surgery and manageability of postoperative pain, however, they still just don't want to proceed with surgery. Would you still always get preoperative studies (chest CT, echo and PFTs) in these patients? I don't generally pursue the studies unless they want to proceed with surgery. And, I don't push them into surgery, reassuring them that they can live normal lives with the defect and that surgery is not mandatory. Is this management incorrect?

Also, what is your age cutoff for surgery? You discussed the optimal age for surgery, but is there an age cut-off that you hold to? Sometimes patients don't get sent to me till they are 17/18 years old -- i.e. after their pubertal growth spurt. Is this too late for surgical correction?

I would appreciate any suggestions you may have! Thank you so much!

Begum

Dr. Kelly, Thank you so much for such a wonderful podcast and review of the management of Pectus! I have a few questions that weren't addressed: What do you do for patients who don't want surgery? I have a handful of patients with moderate to severe depressions and minor symptoms (mainly intermittent chest pain and respiratory fatigue with exertion) who do not want surgery. They are not heavy into exercise or sports and the depression doesn't bother them enough psycho-socially to pursue surgical intervention. I counsel them regarding the low risk of surgery and manageability of postoperative pain, however, they still just don't want to proceed with surgery. Would you still always get preoperative studies (chest CT, echo and PFTs) in these patients? I don't generally pursue the studies unless they want to proceed with surgery. And, I don't push them into surgery, reassuring them that they can live normal lives with the defect and that surgery is not mandatory. Is this management incorrect? Also, what is your age cutoff for surgery? You discussed the optimal age for surgery, but is there an age cut-off that you hold to? Sometimes patients don't get sent to me till they are 17/18 years old -- i.e. after their pubertal growth spurt. Is this too late for surgical correction? I would appreciate any suggestions you may have! Thank you so much! Begum

From Dr Kelly:::

Dr. Akay,

For patients who do not want surgery, we discuss use of the vacuum bell. This device has been in use in Europe for ten years, and we have been using it for about two years in our clinic. It is most effective on younger patients with very pliable chests (for example, children less than 10 or 11 years old). However, the groups in Basel, Switzerland, and St. Etienne, France, have seen success in older children and adults as well.

The question, “what happens if we do nothing?”, remains poorly answered. While some live through adulthood without symptoms, the greater attention being given to adult repair has led to studies which suggest development of symptoms in the third or fourth decade of life may be common (vide infra).

Repair by Nuss procedure in adulthood is now well recognized; at a recent Chest Wall International Group meeting repair of a 72 year-old was reported.

Regards,
Robert Kelly, M.D.

Kragten HA, Siebenga J, Hoppener PF, et al. Symptomatic Pectus excavatum in seniors (SPES): a cardiovascular problem? Neth Heart J. 2011; 19(2):73-78.

Casamassima MGS, Gause C, Goldstein SD, et al. Patient satisfaction after minimally invasive repair of Pectus excavatum in adults: Long-term results of nuss procedure in adults. Ann Thorac Surg 2016 http://dx.doi.org/10.1016/j.athoracsur.2015.09.102

Pilegaard HK. Extending the use of Nuss procedure in patients older than 30 years. Eur J Cardiothorac Surg 2011;40:334-7

From Dr Kelly::: Dr. Akay, For patients who do not want surgery, we discuss use of the vacuum bell. This device has been in use in Europe for ten years, and we have been using it for about two years in our clinic. It is most effective on younger patients with very pliable chests (for example, children less than 10 or 11 years old). However, the groups in Basel, Switzerland, and St. Etienne, France, have seen success in older children and adults as well. The question, “what happens if we do nothing?”, remains poorly answered. While some live through adulthood without symptoms, the greater attention being given to adult repair has led to studies which suggest development of symptoms in the third or fourth decade of life may be common (vide infra). Repair by Nuss procedure in adulthood is now well recognized; at a recent Chest Wall International Group meeting repair of a 72 year-old was reported. Regards, Robert Kelly, M.D. Kragten HA, Siebenga J, Hoppener PF, et al. Symptomatic Pectus excavatum in seniors (SPES): a cardiovascular problem? Neth Heart J. 2011; 19(2):73-78. Casamassima MGS, Gause C, Goldstein SD, et al. Patient satisfaction after minimally invasive repair of Pectus excavatum in adults: Long-term results of nuss procedure in adults. Ann Thorac Surg 2016 http://dx.doi.org/10.1016/j.athoracsur.2015.09.102 Pilegaard HK. Extending the use of Nuss procedure in patients older than 30 years. Eur J Cardiothorac Surg 2011;40:334-7
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