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The basis of decision making

The basis of decision making

 

The decision to carry out corrective surgery to the chest wall is not based on the results of functional tests alone. Clinical examination and a comprehensive discussion between doctor and patient are the basis on which further treatment is planned.

In mild cases, a period of observation with follow-up is usually suggested. Worsening of findings as the body develops can be a reason for proceeding to corrective surgery. On the other hand, if the findings remain insignificant, treatment is limited to conservative measures (such as physiotherapy to build up muscles and improve posture).

 

Severity

The severity of a chest wall deformity can be quantified, based on the ratios between the breadth and the depth of the ribcage and between the widths of the upper and lower openings of the ribcage. The so-called funnel chest index (Trichterbrustindex, TBI) measures the position of the breastbone (sternum) relative to the spine. The TBI compares the outer distance between breastbone and spine at the upper and lower thoracic entrance levels. Because of the leverage exerted by the breastbone, this index correlates with displacement of the heart, and so with adverse effects on its function. The TBI is easy to assess in the clinical examination and is useful for pre- and postoperative follow up.
The Haller index (HI), also known as the pectus index, is defined as the ratio of the transverse diameter (the horizontal distance of the inside of the ribcage) and the anteroposterior diameter (the shortest distance between the vertebrae and sternum), based on CT or MRI scans.
It is important not only to consider single measurements, but also the trends over time as the ribcage develops.

 

Medical Factors

Children and young people are usually free of symptoms, as the chest wall is elastic in the first two decades of life, and as the organs develop gradually they have time to adapt. But with increasing age there is accumulation of symptoms such as a racing heartbeat (palpitations) on mild exertion, and patients tire easily. These symptoms can be caused, particularly in funnel chest, by narrowing of the chest cavity. The heart does not have enough room to expand in order to increase its stroke volume when required, and so needs to pump faster. The expansion of the lungs can also be restricted.

Psychological Factors

Individual suffering depends very much on subjective factors. A common reason for treatment is the psychological strain that can impair self-confidence and enjoyment of life as early as adolescence.
In certain cases, conspicuous deformities lead to behavioural difficulties, and in adults there can be problems with relationships. In some cases there can even be thoughts of suicide. The support of a psychotherapist can occasionally be extremely helpful. But it is important in every case to clarify the organic clinical findings and obtain an assessment from an experienced specialist.

 

Age

Chest wall corrective surgery in early childhood should only be undertaken in exceptional circumstances. In infants and young children it is very rare for there to be any urgent indication for surgery. ‘Prophylactic’ surgery in this age group is usually unwise. In any case children should be old enough to be able to co-operate with pre- and post-operative physiotherapy.
The chest wall should have reached a degree of stability by the time of the operation. Otherwise, with many of the techniques, there is an increased risk of relapse in spite of initially good results. So we recommend that corrective surgery – aside from exceptional cases – is postponed until after puberty.
The minimal access method can in principle be used in all age groups with comparable success. The age range of our patients stretches from 2 to 60 years old, and two thirds are adolescents. The method can be combined with other procedures, such as heart surgery or – in women – breast reconstruction or insertion of breast implants.

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