Funnel breast

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Classification according to ICD-10
Q67.6 Pectus excavatum
congenital funnel chest
ICD-10 online (WHO version 2019)
Funnel breast

A funnel chest ( pectus excavatum sive infundibulum ) is a depression in the front wall of the chest . The area around the breastbone is drawn in towards the spine. The funnel chest is associated with changes in the cartilage connections between the sternum and ribs . The funnel breast (as a result of rickets ) is also known as the cobbler breast .

frequency

The incidence is approximately 1: 300 to 1: 400 births. Boys are three times more likely to be affected than girls. Familial accumulation is observed in 35% of the cases. The funnel chest also occurs more frequently in Marfan's syndrome , Poland syndrome and fetal alcohol syndrome .

causes

The causes of the funnel breast are unclear. Excessive growth of the costal cartilage is widely believed to be the cause; however, this assumption has been questioned in recent years.

In some syndromes , the funnel breast has a characteristic, e.g. B. in cranioectodermal dysplasia .

consequences

Depending on the degree of severity, the functions of the heart and lungs can be impaired, and physical malpositions also occur. The shoulders are usually inclined forward and hang slightly, the back shows kyphosis (hump) , the stomach protrudes. Increased pressure in the abdomen (abdomen) puts strain on the cardia and can lead to chronic reflux esophagitis .

Diagnosis

Haller index for the quantification of a funnel breast determined with the MRI. The normal value is 2.5. In this example it is around 4.7.

The chest deformity is externally visible. Usually it occurs in the first year of life, but the deformation increases until the end of growth. The full extent can be made visible using CT . Consequential damage is searched for by means of a lung function test and EKG or echocardiography . In addition, the spine should be examined, e.g. B. X-rays to rule out other clinical pictures.

The Haller index can be determined with the aid of a CT examination or magnetic resonance imaging . This index is widely used to indicate the size of the funnel breast. It is calculated as the greatest distance between the right and left ribs divided by the smallest distance between the breastbone and the spine. Another measure for the depth of the funnel breast, which can be determined with simpler means, is the distance between the lowest point of the funnel breast and a ruler or tight band placed across the nipples; sometimes this value is also divided by the total depth of the chest.

treatment

The incorrect posture can be corrected by means of physiotherapy , but the funnel chest cannot. Consequential damage can be limited or even prevented by training the back muscles in order to counteract the incorrect strain on the intervertebral discs.

The indication for surgical correction of the funnel breast results from the psychological and physical impairment caused by the malformation. The proposed measures can be aimed at a reconstruction of the chest wall (Nuss, Ravitch) or the mere correction of an aesthetic defect (3D implant made to measure). Nuss or Ravitch operations are usually carried out by pediatric or thoracic surgeons , and 3D implants are also performed by plastic surgeons.

Suction cup

The chest should be slowly raised by means of a suction cup through regular use. This method is relatively new, a long-term study was carried out in the university clinic in Jena. This suction cup has to be used for one hour a day over a period of two to three years. Users and the manufacturer consider it possible that the suction cup may make surgical treatment superfluous for some patients in the future.

The length of treatment required to reduce the depth of the funnel depends on the age of the patient, how severe the symptoms are, and how often the suction cup is used. However, due to the lack of long-term results, it is not yet known whether a result achieved by a suction cup treatment will last in the long term.

Orthosis

Another conservative treatment is the use of an orthosis in combination with physical exercises to be carried out, similar to the treatment of the keel chest with a keel chest orthosis . In individual cases, overcorrection may occur, which requires further treatment. Orthosis, physical exercises and suction cup are also used in a combined treatment, but without scientific evidence of the effectiveness or risks of such a treatment.

Minimally invasive technique

Lung training devices that are used in physiotherapy after surgery

In the so-called "nut surgery", which was first described by Donald Nuss in 1998, an individually measured and pre-bent metal bracket is pushed under the breastbone through two small cuts on the sides under the armpits . This pushes the sunken sternum and the affected ribs outwards. The bracket is fixed at the side. In some cases two or three stirrups are also used. The result is immediately visible.

Usually the bar stays in the body for two to three years and is then surgically removed; a longer time is required in the elderly. The method has also been used in Germany since 1999. Because of the small scars, many patients prefer this method to the Mark Michael Ravitch open method.

The minimally invasive funnel chest correction method was methodically developed by Rokitansky, among other things by notching the sternum, thoracoscopic slitting of the costal cartilage and by using a one-piece support implant (metal bracket), where there is no metal abrasion in the body.

Open surgery

The techniques go back to Mark Ravitch or Fritz Rehbein and Hans Hellmut Wernicke.

During the operation, the chest is opened by a vertical incision several centimeters long (in men) or a horizontal incision (in women). The deformed ribs are then severed from the breastbone. Cartilage parts of the deformed ribs are removed. The sternum is sawn, then lifted and fixed with metal brackets. Then the chest is closed again.

The operation ( Minimalized Erlangen Correction Method , MEK), which was further developed by Hans Peter Hümmer in Erlangen , largely dispenses with the complete severing of the ribs. Instead, the ribs at the base of the breastbone are only notched. The tensiometer is used to measure the tension that is necessary to lift the sternum. In comparison to other surgical methods, this procedure shortens the postoperative lying time. It is currently the only one that can show long-term results after several decades and is applicable to both symmetrical and asymmetrical chest wall deformities.

Implant

Image of a 3D implant for the funnel breast
Image of a 3D funnel breast implant

Implants make it possible to treat the pectus excavatum from a purely morphological perspective and thus to partially or completely correct the asymmetry of the breast. The implants are developed on the basis of plaster casts using CAD processes and are made from silicone rubber.

The operation is performed within an hour and under general anesthesia. The surgeon makes an incision about seven centimeters long, prepares the corresponding area in the chest, inserts the implant deep under the muscle and closes the incision again at the end. The hospital stay that the operation entails usually lasts about three days.

Recovery after surgery usually requires only mild pain medication. A surgical bandage is necessary for the first few days after the operation; A compression vest must be worn in the first month after the operation. A follow-up examination for a seroma puncture will be done one week after the procedure. If the operation is performed with minimal complications, the patient can resume normal activities very quickly; d. H. he can go back to work after 15 days and exercise again after three months.

The implant remains for life, but there are no long-term results yet. There is also a lack of clinical studies comparing this method with older and established methods that do not require an implant.

See also

literature

  • F.-M. Häcker, S. Sesia: Conservative and operative correction of the funnel breast. 16 years of experience . In: The pulmonologist. Volume 13, No. 2, March 2016, pp. 124-134. doi: 10.1007 / s10405-016-0032-7
  • Anton H. Schwabegger (Ed.): Congenital Thoracic Wall Deformities. Diagnosis, Therapy and Current Developments . Springer, Vienna / New York 2011, ISBN 978-3-211-99137-4 . doi: 10.1007 / 978-3-211-99138-1
  • Hans Peter Hümmer, Bertram Reingruber, Peter G. Weber, Christian Knorr: Indication and technique of the "minimally invasive" funnel breast correction. Part 1. In: Surgical General. 4/11 2010, pp. 193-200.
  • M. Muschik, A. Wagenitz, H. Zippel: Operative funnel and keel chest correction using a modified method by Mark Ravitch. In: Journal of Cardiac, Thoracic and Vascular Surgery. Volume 12, Number 5, 1998, pp. 226-231. doi: 10.1007 / s003980050047
  • Hans Peter Hümmer: The funnel breast. Correction to the stage and form . Zuckschwerdt, Munich / Bern / Vienna 1985, ISBN 3-88603-128-4 .
  • Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition ibid 1986, ISBN 3-13-352410-0 , p. 57 f. ( Funnel chest and cobbler chest ).

Individual evidence

  1. ^ Johann Deutsch, Franz Schnekenburger: Pediatrics and Pediatric Surgery for Nursing Professions. Thieme Verlag, 2009, ISBN 978-3-13-142811-0 . P. 321.
  2. ↑ a b Rolf Gilbert Carl Inderbitzi, Ralph Alexander Schmid, Franca MA Melfi, Roberto Pasquale Casula: Minimally Invasive Thoracic and Cardiac Surgery: Textbook and Atlas. Springer Science & Business Media, 2012, ISBN 978-3-642-11861-6 , pp. 307-308.
  3. ^ P. Puri, M. Höllwarth: Pediatric Surgery. Springer 2006, p. 97.
  4. ^ A. Hebra: Pectus excavatum at emedicine.medscape.com accessed October 5, 2006.
  5. ↑ funnel chest (pectus excavatum). Freiburg University Medical Center, accessed on September 20, 2016 .
  6. ↑ see e.g. B. as a quote: “The severity of pectus excavatum was also measured with a 30.5-cm (12-in) wood ruler and tape measure in the supine position by placing 1 end of the ruler into the pectus excavatum at the level of the nipples and measuring the depth of the pectus excavatum on the ruler from the tape measure placed circumferentially around the thorax at the nipple level. "Quoted from: PK Canavan, L. Cahalin: Integrated physical therapy intervention for a person with pectus excavatum and bilateral shoulder pain : a single-case study. In: Archives of physical medicine and rehabilitation. Volume 89, Number 11, November 2008, pp. 2195-2204, doi: 10.1016 / j.apmr.2008.04.014 . PMID 18996250 .
  7. ↑ EB Rebeis, JR Campos, LF Moreira, AC Pastorino, PM Pêgo-Fernandes, FB Jatene: Variation of the Anthropometric Index for pectus excavatum relative to age, race, and sex. In: Clinics (São Paulo, Brazil). Volume 68, number 9, September 2013, pp. 1215–1219, doi: 10.6061 / clinics / 2013 (09) 07 . PMID 24141837 , PMC 3782722 (free full text).
  8. ^ F. Schier, M. Bahr, E. Klobe: The vacuum chest wall lifter: an innovative, nonsurgical addition to the management of pectus excavatum. In: Journal of Pediatric Surgery. 40 (3), 2005, pp. 496-500.
  9. ↑ Non-surgical sunken chest treatment device may eliminate surgery. Mass Device, November 2012, accessed October 22, 2013 .
  10. ^ Raver-Lampman: First patients in US receive non-surgical device of sunken chest syndrome. Eurek Alert, November 2012, accessed October 22, 2013 .
  11. ↑ M. Lopez, A. Patoir, F. Costes, F. Varlet, JC Barthelemy, O. Tiffet: Preliminary study of efficacy of cup suction in the correction of typical pectus excavatum. In: Journal of Pediatric Surgery. Vol. 51, No. 1, 2016, pp. 183-187, doi: 10.1016 / j.jpedsurg.2015.10.003 .
  12. ^ The Dynamic Remodeling method (DR method). Centro Clinico Orthopectus, accessed February 24, 2016 .
  13. ^ SA Haje, DP Hase: Overcorrection during treatment of pectus deformities with DCC orthoses: experience in 17 cases. In: International Orthopedics. Vol. 30, No. 4, 2006, pp. 262-267. PMID 16474937 , doi: 10.1007 / s00264-005-0060-0 .
  14. ↑ External Brace. Retrieved May 26, 2016 .
  15. ↑ Pectus Excavatum. The London Orthotic Consultancy, accessed February 24, 2016 .
  16. ↑ Órteses e Próteses. orthopectus.com, accessed April 17, 2016 (Portuguese).
  17. ↑ D. Nuss, RE Kelly Jr. et al.: A 10-year review of a minimally invasive technique for the correction of pectus excavatum. In: J Pediatr. 33, 1998, pp. 545-552.
  18. ↑ D. Nuss, RE Kelly Jr. et al .: Repair of pectus excavatum. In: Ped Endosurg & Innovat Techn. 2, 1998, pp. 205-221.
  19. ↑ FAQ: Up to what age can you have the nut correction carried out? ( Memento from January 6, 2015 in the archive.today web archive ) accessed on August 19, 2007.
  20. ^ Rokitansky Method in Pediatric Surgery. Springer Verlag, 2009, ISBN 978-3-540-34032-4 .
  21. ^ MM Ravitch: The operative treatment of pectus excavatum. In: Ann Surg . 129, 1949, pp. 429-444.
  22. ^ F. Rehbein, HH Wernicke: The operative treatment of the funnel chest. In: Arch Dis Child . 32, 1957, pp. 5-8.
  23. ↑ HP Hummer, P. Klein, S. Simon: Techniques and experiences in funnel chest operations. In: Langenbecks Arch Chir Suppl Kongressbd. 1992, pp. 401-409.
  24. ↑ P. Weber: Today it's done gently. In: The general practitioner. 20/2005, pp. 39-42.
  25. ^ André, M. Dahan, E. Bozonnet, I. Garrido, J.-L. Grolleau, J.-P. Chavoin; Pectus excavatum: correction par la technique de comblement avec mise en place d'une prothèse en silicone sur mesure en position rétromusculaire profonde ; Encycl Méd Chir, Elsevier Masson SAS - Techniques chirurgicales - Chirurgie plastique reconstructrice et esthétique, 45-671, Techniques chirurgicales - Thorax, 42-480, 2010.
  26. ↑ Ho Quoc Ch, Chaput B, Garrido I, André A, Grolleau JL, Chavoin JP; Management of breast asymmetry associated with primary funnel chest ; Ann Chir Plast Esthet. Elsevier Masson SAS; 2012 Aug 8: 1-6.
  27. ↑ JP. Chavoin, A.André, E..Bozonnet, A.Teisseyre, J..Arrue, B. Moreno, D. Glangloff, JL. Grolleau, I. Garrido; Mammary implant selection or chest implants fabrication with computer help ; Ann.de chirurgie plastique esthétique (2010) 55,471-480.
  28. ↑ Jean-Pierre Chavoin, Jean-Louis Grolleau a. a .: Correction of Pectus Excavatum by Custom-Made Silicone Implants. In: Plastic and Reconstructive Surgery. 137, 2016, p. 860e, doi : 10.1097 / PRS.0000000000002071 .

Web links

Commons : funnel chest  - collection of images, videos and audio files