Pectus is not destiny!

The owner of this slogan is Assoc. Dr. Hasan Ersöz. We had a little chat with my teacher Hasan about pectus disease, which is his special interest. And I started to ask my teacher… What is Pectus? “Pectus” means rib cage in Latin. Pectus excavatum is the collapse of the anterior chest wall, known as “shoemaker’s chest”, towards the inside of the chest cavity. Pectus carinatum, which is another pectus deformity, is called “pigeon chest”. The fact that the anterior chest wall is protruding this time. Pectus Why does it happen? Although it has not been clearly revealed by geneticists that it is genetic yet, I think it is a genetic disease. Because 40% of children with these deformities have been shown to have similar thoracic cage deformities in their family members. In addition, new studies showing some potential genomes have begun to be published. For this reason, it is not mentioned as genetic in the literature yet, but as “there is a familial predisposition”. Is Pectus a Common Condition in the Community? It is a literature information that the shoemaker’s breast is observed once in 300-400 live births, and the pigeon’s breast is observed once in 1000 live births. We see it a lot in practice. In the light of these data, we can say that the more individuals in need of braces in the society, the higher the number of individuals with pectus. For example, if we take the literature information as a basis, we can calculate that there are about 12,500 pectus patients in the city of Izmir with a population of approximately 4.5 million. However, unfortunately, it is not mentioned as much as the need for braces and is thought to be a rare condition for many reasons, such as the fact that the deformity remains in the clothes and becomes more evident especially in adolescence and that these ages hide the situation from the families due to the efforts of the children to protect their privacy. Why is pectus awareness important? In other words, what happens if the deformity is not corrected? Is it just an aesthetic issue? You touched on an important issue. If this condition is not treated, the inward collapse from infancy will steal from the heart and lung volume. Although cardiologists write reports that the heart is not exposed to compression in the “classical echocardiography” ultrasound performed over the chest, we see that the hearts of these patients, especially the “right ventricle”, are exposed to compression during the surgeries. At the International Chest Wall Congress (Chest Wall International Group Congress, of which I am a member) that I attended in September 2022 in Barcelona, ​​this issue was emphasized and it was stated that heart pressure can be demonstrated not with “classical echocardiography” but with echocardiography viewed from inside the esophagus with endoscopy. Therefore, I believe the heart pressure rate is much higher than reported or predicted. Apart from the heart and lung pressure, another important point is the pressure on the upper part of the esophagus and stomach. It causes excessive vomiting in infancy, reflux complaints and early satiety in the later period. Therefore, you can see that almost all of these children are weak. Inadequate nutrition leads to growth retardation. Because the golden ages for human development are infancy and childhood. In particular, patients cannot tolerate even the slightest loss of volume during these periods of development. A bone deformity that steals volume from the lungs, heart, stomach and esophagus is unacceptable. The most common symptom of this disorder is a decrease in effort tolerance. In other words, even if patients do not complain of early fatigue under normal conditions, patients get tired more quickly during exercise than their peers. For example, while their peers can run up 5 flights of stairs, these children can get stuck on the third floor. Because the child’s heart and lung volume has been stolen. There’s something I always say to moms. “Fill water with a measuring cup into the hollow on the child’s chest. I say, “How many milliliters of volume is filled, that much volume is stolen from the heart, lungs, esophagus and stomach”. Pectus can also create direct pressure problems besides stealing volume. For example, a patient of mine had a rhythm problem due to the pressure in his heart. Various cardiologists used different drugs for this, and even it was said that he had an extra focus in his heart, and the catheter was inserted into his vein and the catheter was sent to the heart, and the burning process was applied, but the rhythm disorder did not improve. This patient came to me to have pectus surgery (Nuss surgery). During the operation, the rhythm disorder improved. After that, it never deteriorated again without the need for any medication. Because the cause of the rhythm disorder was not the heart. The cause of the disorder was the pressure exerted by the pectus on the heart. Well, if you ask what is the symptom of this rhythm disorder, that is, what is its reflection to the patient, it is palpitation. Because palpitation is the second most common symptom of pectus after a decrease in effort tolerance. Pectus doesn’t just cause them. It also causes posture disorders in children from an early age. Almost all of the patients have a forward-leaning, hunched-over, shoulder-head-pointing posture (we call it hook shoulder), and when viewed from the outside, they have a very bad and insecure posture. Apart from this, pectus can be accompanied by the bending of the spine to the right and left, which we call scoliosis, in 25% of the patients. It should not be difficult for you to guess the pain caused by the spine that these conditions will cause in the coming years. It is necessary to correct the pectus, not for today (young age), but to be comfortable in old age. Because heart-lung volume loss and compression, spinal problems may not have given any of these symptoms in youth. However, I recommend correction at an early age in order not to experience regret in the period when heart and lung functions will be needed most in old age or when spine and joint pains will increase. It may seem like it doesn’t cause any problems for that day, but even if there is a slight pressure on the right ventricle of the heart and this situation lasts for 30-40-50 years, it will definitely cause various problems on the heart. You don’t need to be a doctor to think about it, it’s a simple physics rule anyone can think of. Therefore, we also operate on patients over the age of 40 who are aware of the situation and think that it is profitable to return from the loss and who want to invest in themselves in their old age. So far we have only touched on the physiological part of it. But there is also an aesthetic and psychological aspect. What I am talking about is not an arbitrary aesthetic concern in the form of filling botox. I want to draw attention here. Elimination of a sense of disability. Look, I have listened to so many patients and witnessed dramatic discourses. For example, a patient of mine said that he had never been to the sea or the pool in his life. Because he was afraid to take off his shirt. Another patient of mine said that he checks for wind before going out because it sticks to his t-shirt in the wind, showing the deformity. In the heat of Izmir, I saw the one who wore a coat on a summer day, and the one who broke up with his fiancé because of this. The aesthetic concern we are talking about is never an arbitrary concern. Psychiatrists have also focused on this issue; They found 82% lack of self-confidence and 78% anxiety disorder in children with pectus. Individuals are not at peace with themselves. Many psychiatric cases such as major depression have been reported in the literature. For this reason, psychiatrists have called this condition “mental deformity” in the literature. Although my answer is long, I thank you again for your important question. In summary, if pectus is not recognized and treated, it negatively affects every aspect of life, both mentally and physically, from vomiting of breast milk in infancy to spinal pain in old age. You always talked about collapse. Do pigeon chests have similar problems? You are right. Of course, there is no heart, lung, esophagus and stomach compressions and volume stealing in the pigeon chest. However, posture disorder, spine problems, aesthetic and psychological problems are unfortunately seen in the same way. For these reasons, they also need to be corrected. Can families notice this in infancy? 1/3 of the patients can be noticed in infancy. But if the deformity is not evident yet, 2/3 of it can be skipped at that time. For this reason, it is very important to provide awareness and therefore treatment at an early age. Generally, the most common age of admission is adolescence, when rapid growth occurs. In the rapid growth period of children, the deformity, which was vague before, can also become evident by growing in direct proportion to the height. In a group of patients, this condition can be missed even in adolescence. Since adolescence coincides with the period when children’s sense of privacy is at a high level, children may not even show their breasts to their families. Those living in coastal cities such as Izmir are more fortunate in this regard, because families can become more aware of the situation, even when swimming in the sea. However, for individuals living in areas far from the sea, the number of patients and families who realize the situation and go to the doctor is even lower. Do pectus deformities resolve spontaneously or, for example, by doing sports, without treatment? Since this is a genetic problem, the DNA is coded to enlarge the breast inward or outward, and it does not correct itself. In fact, as the patient grows, the deformity becomes more pronounced in direct proportion to this. Pectus does not improve with sports alone. Let me show you the photos of people who have been involved in various sports for many years and have achieved very good muscle mass for you to share with our readers. As can be seen here, no matter how good your body is, this deformity does not improve with sports alone. But of course, there are points where sports are beneficial on pectus. For example, it is very useful to do other exercises that will strengthen the back muscles, other than supine swimming, in correcting the posture disorder. However, the collapse or protrusion in the anterior part of the rib cage does not improve with sports alone. Exercises performed under the guidance of a physiotherapist after or concurrently with the treatment may help to respond to the treatment. Any celebrities with pectus? Numerous. If you ask me by heart, the first thing that comes to my mind is Sylvester Stallone, the star of the movie Rocky. Look, he is one of those who can’t get rid of pectus even though he has a good body. I think it was skipped… Sorry. Let alone the society, even many physicians are not aware of the situation. And even in the thoracic surgery community, pectus is a stepchild issue. For this reason, most physicians, unfortunately, can make erroneous statements to patients such as “nothing will happen, it will pass, let them do sports, grow up to be 15 years old, then they will be operated on…”. The group of physicians that I do the most work for awareness is family physicians and pediatricians. Because they see the children the most. It is important that the first doctor notices. But a greater importance is for parents to notice. This is my biggest effort. In this context, I started the project “open my mother breast”. I will have other awareness projects in the future. I guess early detection of pectus is important to prevent potential problems from an early age, isn’t it? Yes, it is very important to prevent the problems I have mentioned early. For example, if the deformity is corrected before the hump is formed, there is no need for further treatment for the hump. Because the bones are shaped when they are soft. Or, if the heart-lung is freed from compression at an early age, these functions will not be stolen in the child’s golden age, which is growth development. Children do not vomit, they eat better, develop better. Apart from these functional advantages, one of the most important benefits of early detection is that the problem is prevented before the child is exposed to psychological effects. For example, a child will start primary school at the age of 6-7. Kids are cruel. School friends can create many problems for these children. In the words of psychiatrists, this situation is called “peer bullying”. However, if the pectus is removed in the pre-school period, such a problem will be prevented before it happens. Thus, the situation will be resolved without leaving a lasting effect on child psychology. In addition, while these deformities can be treated simply without surgery at an early age, their treatment will become much more difficult in later years. Yes, by the way, let’s talk about pectus treatments. Can you explain the pectus treatment options? Certainly. We have non-surgical treatment options up to the age of 17 for shoemaker’s breast and pigeon’s breast. We apply these non-surgical treatments until the age of 17, as the priority is always the most cost-effective and easiest treatment that requires the least intervention for the patient. In non-surgical treatment, medical devices called “orthotics” for pigeon chest and “vacuum bell” for shoemaker chest are used. Sometimes we can apply bandage treatment for rib tips protrusion. Patients come for examination. We determine the appropriate one. There are several brands that sell them. We do not work with a particular brand. We try to help families’ budgets by choosing the most economical product among the products that we think will be beneficial for the patient. There are vacuum devices in the market for 3500 TL and 8500 TL at the moment. If the patient’s chest has hardened, he has reached the age of 16, I recommend the 8500 TL one because there is little time left to correct it and his chest is hard. But for those who come at a young age, I can choose the vacuum, which is 3500 TL, because it has both a size option and an economical one. Again, in some special cases, I may prefer products in intermediate form. For example, each brand has different size options. When a special measure is needed, I guide accordingly. The fact that I have not worked with a single brand, a single company creates trust on patients, while protecting my own ethical value. In this way, after determining the product and size suitable for the patient, I send the family to the dealer of the relevant product by prescribing it. They buy products from there and come back again. This time, I explain in detail how to use the products, I make markings if necessary. 6 weeks after patients start using these products, I call them for control. Because if they do wrong application, I can realize this in the early period, in the sixth week, and I prevent the mistake before it’s too late. Subsequent check-ups are every 6 months, i.e. twice a year. In this way, I follow our patients regularly. In order to further assist patients coming from distant cities during these follow-ups, we also offer the option of online examination through our E-Nabız compatible software in accordance with the personal data protection law, after the relevant KVKK approval of the patients and their relatives. Follow-up is important, because sometimes the rib cage may want to collapse again, this time from different parts, not the area where vacuum is used persistently. Because the patient’s DNA is coded to collapse. In such cases, thanks to these follow-ups, we can detect this early and change the treatment according to the new form. For example, we can apply a different size and shape of vacuum to the patient. The important thing is to ensure that the patient’s bones harden properly when he reaches 18, and to protect the patient from the negative effects of pectus until that time. For this reason, it is important to continue the follow-up twice a year in non-surgical treatment. Patients over the age of 17 usually require surgery. These operations are divided into two. A “real treatment surgery” in the form of pulling the bone to where it should be, or “correcting the appearance and psychological effects” by filling the collapsed bone with a silicone implant. Of course, the main goal should be real treatment. However, for real treatment surgery, the patient needs to withdraw from daily life for a month, need someone to take care of him, and struggle with the patient’s pain. Moreover, the patient cannot do sports for the first 3 months after the surgery, and then contact sports should be restricted until 3 years after the bars are removed again. The patient’s work-school may not allow him to withdraw from daily life for a month, or he may not have anyone to take care of him. Apart from this, the patient may be an athlete and it may not be possible to stay away from sports for 3 years. For example, the patient lives abroad and it may be problematic to come and go. For this reason, they may not want to undergo a second surgery. Or he might say, “Save me at once, I don’t want to deal with this again.” Apart from these, they may also be afraid of post-operative pain and the low risk of heart injury from actual correction surgery. Our recommendation to patients with all these problems is to hide the deformity by placing a 3D silicone implant specially designed according to the patient’s tomography on the collapsed part of the bone. “Real treatment surgeries” are divided into two as open and closed methods. While the open method is called “Ravitch surgery”; The closed method is called “Nuss surgery” for shoemaker’s chest, and “Abramson surgery” for pigeon chest. Of course, more than 90% of the surgeries are closed methods, as we have determined the treatment method in an algorithm that goes from easy to difficult. It is based on the fact that a steel bar lifts the chest with a camera (or if the pigeon has breast disease, that is, if the rib cage is protruding, a subcutaneous tunnel is created and the steel bar presses the bone down over the bone). The bars remain in place for 3 years, the patient is followed up intermittently, and after 3 years, the bars are removed again with a surgery. In open surgery, on the other hand, there is an advantage that the patient is operated only once. However, in addition to the fact that large incisions are made for a plastic surgery and more aggressive surgery such as the removal of some bone and cartilage fragments is required, the high recurrence rate of pectus in the following years stands out as negative factors for open surgeries (Ravitch). Images of a patient with Pectus Excavatum corrected by Nuss surgery Images of a patient with Pectus Carinatum corrected by Abramson surgery Images of a case of Pectus Arcuatum corrected with the open surgery Ravitch technique Thank you very much for this nice interview. You have informed us and our readers on this important issue, the pectus. I thank you. Greetings and respects to our dear readers.

Wold Turk TV Dr. From the Pen of Medet Health Program Producer Ahmet Kandemir 09.11.2022