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Melanie Cole (Host):  Welcome to Pediatric Specialty Care Spotlight with Shriners Hospitals for Children in Chicago. I'm Melanie Cole and today, we welcome Board Certified Pediatric and General Surgeon Dr. Srikumar Pillai. He's here to talk about chest wall deformities, what parents and patients need to know, the treatment options available and when the right time for those treatments is. Dr. Pillai, it's a pleasure to have you join us today. What exactly is a chest wall deformity?

Srikumar Pillai, MD (Guest): Well, thanks for having me, Melanie. It's, there are actually a variety of different chest wall deformities, but the ones we see most commonly are of two types. There's a pectus excavatum deformity, which means that the chest is more sunken in. And then there's a pectus carinatum deformity, which means that the chest is actually sticking out more, almost like a bird chest. So, those are the two main ones we've seen in kids and young adults.

Host: How did they form Doctor?

Dr. Pillai: No one's a hundred percent sure. But during growth and development, I think that there's more and more people feel that there's an abnormal connection or an abnormal junction between the ribs and the breastbone or the sternum. So, the ribs when they start growing, they kind of indent in and grow in just because there's an abnormal, there's an abnormal, formation of that area. So, you see, you see these defects even as in infants. But as they get older, they go through growth spurts, they get into adolescence, they become more and more pronounced because as this deformity or this abnormal connection of the ribs begins, when they start developing and growing this deformity becomes more and more apparent. So, as the kids get older, they become more and more pronounced.

Host: So, tell us a little bit about how this affects the children, Dr. Pillai. What kinds of issues or complications might they have and also psychosocial, I imagine there's that particular part involved as well.

Dr. Pillai: Yes. There's a couple of things that, there's a couple of things that go on. So, let's take pectus excavatum. The excavatum would have a little bit more physiologic issues because there's more of a compression on the lungs as well as the heart. So, the heart and the lungs are kind of pushed away because the sternum is actually pushing down into the area. So, with the excavatum, you have more of a physiologic issue because there's a compression effect so that the lungs can be a little bit more compressed and cause restrictive issues with ventilation. And the heart can also be a little bit compressed too, or pushed to the side.

You may see the effects of this. Some kids may not have any effects too. Some kids may have severe affects with cardiac function. Most of the time we see that they have, they're not able to do the same tolerance of activity. So, if they're playing sports, they get tired a lot easier or they can't run as long as their colleagues can. So, you see those types of things going on. There's also a psychological component to this as well. You know, when kids are very self-conscious a lot of time. So, when their chest is really very concave in you know, they don't like to go to the beach. They don't like to go to the pool. They don't like to take off their shirts. It's and from a psychosocial standpoint, it's also pretty bad too. So, that's the excavatum and the carinatum is similar, but the physiologic affects are not there because instead of the chest being pushed in, the chest is actually sticking out. So, it's not causing really compression or anything of any of the underlying organs, but it can still cause the same type of psychosocial effects for the kid.

Host: So tell us what treatments are available.

Dr. Pillai: Well, there's a lot of treatments around. I think that looking at the excavatum, initially people, you know, initially the operation to do this, to fix an excavatum was to take out the abnormal ribs. Restructure the sternum and put a bar underneath this sternum to elevate it into place. And this was an open operation. It was two or three hours. And now since the 1990s, probably maybe 2000, I think it's been maybe 1990s, 20 years, NUS came out with a minimally invasive procedure where you would tunnel a bar under the sternum, but you make two small incisions on either side of the chest and then you would flip the bar and pop the sternum out.

So, that's become the standard now for pectus repairs. The only modification that's been done or that we've been doing is that we also put a scope or a thoracoscope into the chest to watch the bar go under and to make sure it's in the appropriate location. Now, the kids, once these bars are in, they keep these bars for about three years and then we take these out the operating room.

So, the optimum time to do this is usually around their adolescence. So like 12, 14, 16 years old. When they're younger than that and they have a pectus, there's another device that you can use. It's more of a vacuum device and it actually is almost like a big suction cup that kind of sits in the chest and you pump it up and it kind of pulls the sternum out.

And for the younger kids we do offer that to the parents because you really don't want to do the pectus repairs at a really young age because the recurrence rates and the effects of the surgery are really not as good as the older kids. You do want them to get into that growth phase or that phase when they're getting through their adolescence before you do this.

So, those are the two procedures we can do for the excavatum and for the carinatum, really there are surgical procedures to be used for that. You know, everything from the same Ravitch or the open procedure to the a Nuss procedure where the bar, instead of being under the sternum goes on top of the sternum.

But most of the time with these kids, we start with brace therapy. So, if they see us in the clinic, we put a, we have them measured and we put up brace onto this, onto the area where there's going to be constant compression of the sternum, where it sticks out. And then it'll slowly over time, eventually flatten out and the kids would not need any operations at that point.

Host: Wow. That's so interesting Doctor. So, why is Shiners Chicago, the place to bring your child who may have a chest wall deformity? Speak about your staff and your multidisciplinary approach for parents listening.

Dr. Pillai: So, a lot of these kids and Shriners is an excellent place to go because from the nursing staff to the physicians, to anybody involved, the dietary people, everybody's very geared towards the kids. They're the point of all of their attention. So, a lot of these kids do have combination of deformities. They'll have orthopedic anomalies with their spine as well as the pectus anomaly. So, you'll see many of these kids having multiple anomalies and that is a place because of the subspecialties and because of the good orthopedic and spinal surgical care, this is a place that, would be able to handle most of the complex pectuses as well as the spines in a very, unified type of a fashion. It's good because we used to the anesthesiologist and surgeons we're used to these abnormalities there and there's a lot of collegiality and working collaboration and getting these kids fixed up.

Host: Well, it's also really about the experience, the passion and the compassion that you doctors at Shriners Hospitals for Children in Chicago have. It amazes me every time I talk to one of you, Dr. Pillai. So, before we wrap up, tell parents about some of the other things pediatric surgeons provide at the Chicago Shriners Hospital. You can talk about feeding tube access, MIC-KEY buttons. G-tubes. Give parents a little overview of some of the other amazing things you're able to do to help their children.

Dr. Pillai: Absolutely. I think that since we've started at Shriners, we're expanding our services. So, the chest wall deformities are the ones that we had focused on initially, but we're gearing up to provide all pediatric surgical care at Shriners. So, everything from feeding access to kids that you know, have feeding or swallowing issues or require extra nutrition before a major operation, we can do the feeding tubes and the buttons that you mentioned, the MIC-KEY buttons are more low-profile feeding tubes. So we can do those. We do those laparoscopically. So there's no incisions on these kids. It's very minimal. It's a very minimally invasive surgery for these kids. We also are going to be opening up and doing hernias and umbiblical and inguinal hernias and anything really that a child would need surgically, we'd be able to do at Shriners. So, we'd give them the full compliment of pediatric surgical services.

Host: It's great information. What an informative episode. Thank you so much, Dr. Pillai for joining us today. To make an appointment, you can always call 773-385-KIDS. That's 773-385-5437. Or of course you can visit our website at shrinerschicago.org for more info. That wraps up this episode of Pediatric Specialty Care Spotlight with Shriners Hospitals for Children in Chicago. For more health tips and information and updates like you got today, please follow us on your social channels. I'm Melanie Cole.