Scott Webb (Host): Pectus or chest wall deformities range from mild to severe, and experts like my guest today specialize in helping patients with operative and non-operative treatment options to address their medical issues and cosmetic concerns. And I'm joined today by Dr. Marisa Schwab. She's a pediatric surgeon and program director for the Chest Wall Program at Stanford Medicine Children's Health. And I'm also joined by Dr. Stephanie Chao. She's the Trauma Medical Director at Stanford Medicine Children's Health.

Scott Webb (Host): This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. It's nice to have you both here today. As I was mentioning, this is a new topic for me talking about chest wall and pectus and pectus deformities. And it's so great to have you both here and, you know, just really rely on your expertise. And Dr. Schwab, I'm going to start with you. I just want to have you maybe just start by telling us what exactly pectus deformities are and why they are important to know about.

Dr. Marisa Schwab: Thank you, Scott. And thank you for having us today. We're really excited to talk about all things chest wall related. So, chest wall deformities are really an atypical shape of the chest wall. So, it happens when the breastbone, which is also called the sternum, grows unevenly, or the cartilage that connects the ribs to the breastbone grow unevenly. So instead of lying flat, the breastbone either pushes inward or outward.

So, we generally see one of two things: pectus excavatum is the most common version, and that's when your breastbone sinks inward. So, you might hear it called also funnel chest. And pectus carinatum is when the breastbone and ribs push outward. So, it looks like a bird's chest, which is why it's often called pigeon chest.

Host: Interesting. Dr. Chao, like, how does the chest wall program at Stanford Children stand out for children dealing with these defects?

Dr. Stephanie Chao: Our chest wall program is really dedicated entirely to children with these defects so that we can dedicate kind of a very tailored individual approach. Our clinics are blocked out for longer periods of time so that we can educate both the children as well as their parents about this condition.

So, the chest wall program is really a multidisciplinary program. We involve our surgeons. We also involve a team of advanced practice providers, so nurse practitioners and physician assistants who help manage some of the younger children who may not need surgery. We offer a variety of operative as well as non-operative treatments to find what is the right treatment plan for the individual patient we have.

And when it comes to surgery, there is a multidisciplinary evaluation ahead of time. So, we will do pulmonary function testing on some patients. We will do exercise testing, echocardiograms that evaluate the structure of the heart, as well as various radiographic testing, again, depending on the patient. And this individualized treatment plan also extends to after surgery. So, how we treat each child for pain is going to be both standardized in the sense that we know certain pathways will work for this type of patient, but we also take a very individual approach and see whether or not alterations need to be changed to the pathway to suit the child in front of us. So holistically together, that's what creates our comprehensive chest wall program.

Host: Right. Yeah. I love hearing those things. They just bring a smile to my face, you know, individualized, which is great. As a parent myself, I would want that for my children. We all do, of course. And multidisciplinary and really taking your time. All good stuff. And Dr. Schwab, do these defects have any immediate impact on children's health, I guess particularly related to heart and lung function?

Dr. Marisa Schwab: Yeah. It's a really good question. When we think about chest wall deformities, we really focus on the mechanical relationship between the structure of the chest and the function of the organs inside, meaning the heart and the lungs. And if you think of the chest wall as kind of a protective frame, it also has to be flexible enough to allow your heart and lungs to perform at their peak.

 So when you think of pectus excavatum, or sunken chest, the physical position of your breastbone can actually directly compress the heart. For the heart to pump effectively, it has to first be able to expand fully to fill with blood. So if your chest wall is pressing inward, that filling capacity is reduced. And during rest, especially when you're a healthy kid, your body compensates pretty well; whereas when you're in times of intense exercise, when the heart needs to pump much faster and fill more, that the lack of space due to the pectus excavatum can limit your overall cardiovascular efficiency.

 And then, for the lungs to work, the chest wall has to move outward and upward to create space for the air to come in. But when you have a pectus deformity, that elasticity with the chest is often different. So if the chest can't expand fully, then the lungs may not be able to reach their maximum volume. So, that's why many teenagers will describe a sensation of tightness, or they feel like they can't satisfyingly take a deep breath during an intense exercise.

Dr. Stephanie Chao: One of the things that I would add to that is a lot of patients and teens who come to see us are really in the peak of health. So, their chest is still very flexible. They're often still quite athletic. And so if you ask a teen, "Do you have shortness breathing or do you feel like you can't exercise?" A lot of the times, the answer is no, in part because this is all they've known. It's a gradual process that has grown with them. So, it's not as though they were breathing at maximal capacity, and then you restrict them all of a sudden and they notice a difference. So, this is all they've ever known.

But what we have found as we follow patients over time, is that sometimes when they reach adulthood and their chest does not have the natural elasticity of a teen and your bones are starting to harden more, then you do feel some of that restriction. So, that might show up later in life, like in your 30s as you're trying to remain fit, you're trying to keep jogging or running. And what you realize is that your body seems to just hit a ceiling, that you can't push it to where you should. Because for some reason, your body just can't achieve what it wants to in terms of the gas exchange and delivering oxygen to the muscles during exercise, just as Dr. Schwab described. And by that time, you know, because our bones are harder, because we are older in life and we carry more weight, that's when we feel it. And so, we really want to let children and their parents know early on when it is much easier to intervene the options that are available.

Host: Yeah. I see what you mean. It's like, you know, for those who are suffering with this or living with this, it's all they've ever known. But as time goes on, it may become more difficult. So, better to get this and work with them when they're younger. And I guess the natural follow-up doctor is then what do we do if we suspect that our child has a chest wall defect?

Dr. Stephanie Chao: The first thing that a lot of parents ask is, "Did they do this to themselves? Is it because their posture is bad? Is it something that I did?" And so, the answer to all that is no. This is just something that develops most often during puberty, although some children are born with this, and it often can feel like it just shows up overnight. Like yesterday, the chest was normal. And the next time the parents look, there's this huge sunken hole in their child's chest. And it can occur quite quickly, but that's also because children are growing quite quickly during puberty. And during that time, our body is changing in all kinds of ways, including the fact that the cartilage can be sinking in. And it does feel like it's a very sudden dramatic change.

Parents and teens, they don't need to panic about it. This is not immediately life-threatening or life-threatening at all. But this is the time where it is great to come and have a conversation with us, the surgeons who treat this day in and day out. And we can give you a very objective point of view of how this is relative to other patients who might have similar changes in their chest and whether or not treatment is necessary, and what kind of treatment is necessary.

Host: Right. Well then, Doctor, let's just talk about as parents and dealing with our children who are dealing with these issues, deformities, what can we do then to help manage the challenges?

Dr. Stephanie Chao: I think most importantly is to help normalize this. This is not an illness. This is not something that should make children feel like they are different or they cannot achieve certain things. Now, some patients, depending on the degree of the sternum being sunken in, they do have very obvious limitations with what they can do with exercise.

And so once they are engaged with a clinic like ours, we can write them notes for school to excuse them appropriately from exercises they cannot do. And if it's very mild, it may not have anything to do with their chest, it might have to do with something else. And so, really trying to help them figure out and manage expectations about their chest.

And then, over the course of time, really monitoring it together as a group, us as the providers, them as the parents, and the patients who actually have it. And so, we like to see patients before they go through their growth spurt, but really at any point in time is fine. But then we can help manage expectations, use non-operative treatments when they are a possibility, and then help parents and patients decide if and when it is time to do something more interventional.

Host: Yeah. And Dr. Schwab, I'm assuming interventional would mean, in many cases, surgery. So, let's talk about that after surgery. What's the typical recovery process like? And, you know, how soon can kiddos return to sports and normal activities?

Dr. Marisa Schwab: Yeah. Surgery for pectus excavatum has really dramatically changed in the past decade or two decades, where now the standard of care is minimally invasive repair of pectus excavatum, the Nuss repair. And so, that has completely changed the surgery, but also the recovery. So, one of the biggest shifts we've seen in pectus surgery is the use of cryoablation.

What that means is during the surgery, we're able to temporarily freeze the nerves along the chest wall. And it's a game-changer because it means that the intense sharp pain that patients used to experience is largely replaced by a sensation of pressure and/or numbness. So in fact, all of our patients are up and working with our physical therapists the day after surgery, and most of our teenagers are ready to be discharged home the day after surgery and returned to school by a couple of weeks after surgery. So, we used to have very strict activity restrictions after surgery.

However, the last year, Stanford participated in a large multi-institutional study that found that having limited to no activity restrictions after surgery and allowing patients to return to their full activities and busy lives wasn't associated with an increase in complications. So since then, we've modified our protocol and now allow patients to return to aerobic activities when they feel ready—we tell them to listen to their bodies. And then, we see them at one month after surgery and then talk about return to all the other sports that they want to.

Host: Yeah, I feel like we're just scratching the surface here today, but it's really great to have you both here. Dr. Chao, how does Stanford Children's integrate research and innovation into patient care for these conditions?

Dr. Stephanie Chao: Well, we are at the heart of Silicon Valley and all parts of Stanford University are so deeply involved in research that it definitely trickles down to the bedside in our clinic as well. So, as Dr. Schwab mentioned, we have participated in several clinical trials evaluating how we can improve outcomes for patients who have pectus excavatum and undergo surgery.

So, in addition to evaluating whether or not activity restrictions are necessary, we've also looked at how much pain medications do patients really need to take. As the surgeons, it's easy just to prescribe a patient a big bottle of pain medications, and hope that they'll take the medications and make themselves comfortable. But that's not really always the best for patients.

And so, a few of the things that we've done, include, for example, involving cryoablation in the surgery. So when cryoablation was still a new technology, we brought it into our surgical practice. And that is, as Dr. Schwab alluded to, we numb the nerves so that patients feel less pain after surgery, not zero pain, but less pain. In addition to that, we supplement the cryoablation with multimodal pain regimen. So, we don't just give opioids to teenagers. We really try to target the different aspects of pain. So, nerve pain is one aspect we target. The muscle relaxation, we target with a different medication. And altogether, that means that patients really will be exposed to less opioids overall. And with the concerns about teens being around opioids, we really try to minimize that by relying on this more multimodal idea of pain control. And that comes from research and collaboration with other institutions.

Some of the other things that we have done to help our patients and really to decrease the amount of unnecessary kind of intervention that we do, patients used to always get evaluated for pectus excavatum with a CT scan. And a CT scan gives a really pretty picture to the surgeon, but it's a lot of radiation for a developing body. And radiation can predispose children to cancer later in life. And so, we've eliminated radiation, and CT scans altogether from our practice. So, we do get a plain film chest x-ray. The amount of radiation from a plain film chest x-ray is less radiation than if you were to take a cross country flight.

For patients who need more in-depth imaging, we've developed a rapid MRI that actually provides really interesting dynamic information that looks at the compression on both the heart and the lungs in different phases of breathing. And we've also integrated 3D imaging with just a light scanner into our practice. And we were conducting a clinical trial for that, our patients actually got pre and post 3D printed little statuettes of their chest before and after surgery, kind of as a thank you for participating in the trial to help us see if we could use light imaging to replace traditional CT scans as well.

Host: That's so cool. Well, like I said, I think we're just scratching the surface here today. But as we wrap up, Dr. Schwab, what are the most critical things for listeners to remember about chest wall defects?

Dr. Marisa Schwab: I think the first thing is remembering that this is a structural defect, not just a cosmetic one. And if the chest wall is restricting the heart's ability to fill or the lung's ability to expand, no amount of training can overcome that physical limit. And so if your child is hitting a wall or feeling different than their peers, it's worth seeing a chest wall specialist for an evaluation.

 The second thing is it's really never too early or too late to start the conversation. So like Dr. Chao mentioned, growth spurts are usually when these deformities become more apparent and catching things early gives us the widest range of tools, whether that's bracing or specialized physical therapy or minimally invasive surgery. But even if you're at the end of puberty or a young adult, it's not too late to be evaluated.

And then, thirdly, the scary part of surgery has really changed. So with modern techniques like cryoablation and minimally invasive approaches, our goal isn't just to fix the defect. It's really to get your child back on the field, back to stage feeling like themselves again.

And I think our final message to the teenagers listening is that you really deserve to feel at home in your own skin. So whether it's the confidence to take your shirt off at the pool or the deep breath you need to finish a race, you're physical and emotional wellbeing are really equally important. So, you don't just have to live with pectus.

Host: Right. Yeah. As you say, earlier is better, but it's never too late and it's more than just cosmetics. But let's not pretend like cosmetics aren't, you know, something on the minds of teenagers, of course. So, all good stuff. Dr. Chao, we'll finish up with you today. Where can listeners find more information or resources if they suspect a child might have a chest wall defect?

Dr. Stephanie Chao: Please reach out to us. So, our website is chestwall.stanfordchildrens.org. Again, that's chestwall.stanfordchildrens.org. Patients can actually reach out to us directly through our website. There is a patient intake form, patients can submit their own information. For most people, they do need a referral from their primary care doctor, but we will work with you to obtain what it is that you need to be seen by one of our providers here. And we really look forward to discussing with each patient their individualized questions, as it relates to their chest wall anomaly.

Host: That's perfect. I appreciate your time, your expertise today. Great to learn from experts. Thank you so much.

Dr. Stephanie Chao: Thank you.

Dr. Marisa Schwab: Thank you.

Host: And for more information, visit chestwall.stanfordchildren.org. And we hope you found this podcast to be helpful and informative. If you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.