How to assess chest wall deformity in children with pectus excavatum – evaluation of the agreement among methods

Marko Kostić; Aleksandar  Sretenović; Milan  Savić; Marko  Popović; Sanja  Kostić; Davor  Stamenović

doi:10.2298/VSP190430071K

Marko Kostić Clinical Centre of Serbia, Clinic for Thoracic Surgery, Belgrade, Serbia
Aleksandar Sretenović University Children’s Hospital, Belgrade, Serbia
Milan Savić Clinical Centre of Serbia, Clinic for Thoracic Surgery, Belgrade, Serbia
Marko Popović Clinical Centre of Serbia, Clinic for Thoracic Surgery, Belgrade, Serbia
Sanja Kostić University Hospital "Bežanijska Kosa", Belgrade, Serbia
Davor Stamenović Clinic for Thoracic Surgery "ViDia Kliniken", Karlsruhe , Germany

DOI: https://doi.org/10.2298/VSP190430071K

Keywords: child, echocardiography, funnel chest, methods, radiography, severity of illness index, tomography, x-ray computed

Abstract

Background/Aim. Pectus excavatum (PE) is the most common deformity of the frontal aspect of the chest wall in children. A particular dilemma arises about the degree of deformity that should be subjected to surgical treatment. The aim of this study was to compare several morphological methods of evaluating the degree of deformity and determine the matching among them, as well as to determine the connection between the functional and morphological abnormalities of echocardiography. Methods. The study included 35 patients with PE, aged between 7 and 15 years. A noninvasive evaluation of chest deformity was carried out in all patients by photographic method (surrogate of clinical examination), native X-ray imaging, and computed tomography (CT), as well as by echocardiographic examination. Results. In our group of patients, males were more common (67.5%), as well as children with the Haller index (HI) > 3.5 [represented in most children (86.7%)]. A significant correlation of the index of the affected sternum segment (ASt) and the total length of the sternum (ASt/LSt) determined by the photographic method with that determined by the CT scan of the chest was established (p = 0.001). In addition, the correlation between HI, determined by the X-ray method and CT images was presented (p = 0.012). In contrast, despite the high frequency of echocardiographic abnormalities (69%), those were not mutually correlated with the degree of pronounced morphological deformities of the chest wall. Conclusion. A detailed clinical examination and photographic evaluation method, combined with the X-ray method, can determine the severity of deformity with a high degree of agreement with the CT chest findings. In this way, it is possible for children with PE, who are not candidates for surgical treatment, to be spared from repeated CT scans that are carried out in order to monitor the development of chest deformities with growth. Echocardiographic evaluation remains an integral part of the assessment of children with PE.

References

Shamberger RC. Congenital chest wall deformities. Curr Probl Surg 1996; 33(6): 469‒542.

Abid I, Ewais MM, Marranca J, Jaroszewski DE. Pectus Excava-tum: A Review of Diagnosis and Current Treatment Options. J Am Osteopath Assoc 2017; 117(2): 106‒13.

Emil S. Current Options for the Treatment of Pectus Carina-tum: When to Brace and When to Operate? Eur J Pediatr Surg 2018; 28(4): 347‒54.

Cartoski MJ, Nuss D, Goretsky MJ, Proud VK, Croitoru DP, Gustin T, et al. Classification of the dysmorphology of pectus excavatum. J Pediatr Surg 2006; 41(9): 1573‒81.

Daunt SW, Cohen JH, Miller SF. Age-related normal ranges for the Haller index in children. Pediatr Radiol 2004; 34(4): 326‒30.

Blanco FC, Elliott ST, Sandler AD. Management of congenital chest wall deformities. Semin Plast Surg 2011; 25(1): 107‒16.

Fokin AA, Steuerwald N, Ahrens WA, Allen KE. Anatomical, histologic, and genetic characteristics of congenital chest wall deformities. Semin Thorac Cardiovasc Surg 2009; 21(1): 44–57.

Park JM, Varma SK. Pectus excavatum in children: diagnostic signiﬁcance for mitral valve prolapse. Indian J Pediatr 1990; 57(2): 219–22.

Sabiston JH Jr. Congenital deformities of the chest wall. In: Sabiston JH, editor. Textbook of Surgery. Philadelphia: WB Sauders Co.; 1997. p. 1888‒96.

Nowak H. Dieerblische Trichterbrust. Duetsche Med Wchnschr 1936; 62: 2003. (German)

Jaroszewski DE, Fonkalsrud EW. Repair of pectus chest de-formities in 320 adult patients: 21 year experce. Ann Thorac Surg 2007; 84(2): 429-33.

Salamanca A, Girona A, Padilla MC, Sabatel RM, Gonzales-Gomez F. Prenatal diagnosis of pectus excavatum and its rela-tion to Down’s syndrome. Ultrasound Obstet Gynecol 1992; 2(6): 446‒7.

Shamberger RC, Welch KJ, Sanders SP. Mitral valve prolapse as-so-ciated with pectus excavatum. J Pediatr 1987; 111(3): 404‒7.

Kilda A, Basevicius A, Barauskas V, Lukosevicius S, Ragaisis D. Radiological assessment of children with pectus excavatum. Ind J Pediatr 2007; 74 (2): 143‒7.

Potts WJ. The Surgeon and the Child. Philadelphia, PA: W.B.Saunders, 1959.

Yoshida A, Uemura S, Yamamoto M, Nouso H, Kuyama H, Muta Y. Correlation of asymmetric chest wall deformity and growth in patients with pectus excavatum, J Pediatr Surg 2013; 48(4): 771–5.

Kelly RE Jr. Pectus excavatum: historical background, clinical picture, preoperative evaluation and criteria for operation. Semin Pediatr Surg 2008; 17(3): 182–93.

Fonkalsrud EW. Current management of pectus excavatum. World J Surg 2003; 27(5):502–8.

Colombani PM. Preoperative assessment of chest wall de-formities. Semin Thorac Cardiovasc Surg 2009; 21(1): 58–63.

Davis JT, Weinstein S. Repair of the pectus deformity: results of the Ravitch approach in the current era. Ann Thorac Surg 2004; 78(2): 421–6.

Nuss D, Kuhn M. Our approach: minimally invasive surgical repair of pectus excavatum. Contemp Surg 2007; 63: 444–51.

Haller JA Jr, Colombani PM, Humphries CT, Azizkhan RG, Loughlin GM. Chest wall constriction after too extensive and too early operations for pectus excavatum. Ann Thorac Surg 1996; 61(6): 1618–24; discussion 1625.

Kim DH, Hwang JJ, Lee MK, Paik HC. Analysis of the Nuss procedure for pectus excavatum in different age groups. Ann Thorac Surg 2005; 80(3): 1073–7.

Pilegaard HK, Licht PB. Routine use of minimally invasive sur-gery for pectus excavatum in adults. Ann Thorac Surg 2008; 86(3): 952–6.

Lawson ML, Cash TF, Akers R, Vasser E, Burke B, Tabangin M, et al. A pilot study of the impact of surgical repair on disease-specific quality of life among patients with pectus excavatum. J Pediatr Surg 2003; 38(6): 916‒8.

Saint-Mezard G, Duret JC, Chanudet X, Larrue J, Bonnet J, Bri-caud H. Mitral valve prolapse and pectus excavatum. Fortui-tous association or syndrome? Presse Med 1986; 15(9): 439. (French)

Warth DC, King ME, Cohen JM, Tesoriero VL, Marcus E, Wey-man AE. Prevalence of mitral valve prolapse in normal chil-dren. J Am Coll Cardiol 1985; 5(5): 1173‒7.

Nuss D, Croitoru DP, Kelly RE. Congenital chest wall deformi-ties. In: Ashcraft KW, Holcomp GW 3rd, Murphy JP, editors. Pe-diatric Surgery. 4th ed. Philadelphia, PA: Elsevier Saunders, 2005. p. 245‒63.