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Dr. Fizan Abdullah: we have a dedicated group of specialists, including not just surgeons, but advanced practice providers, orthotists, physical therapists. We work in partnership with our cardiologists and pulmonary doctors to really optimize the care of these kids.

Scott Webb: Lurie Children's Chest Wall Deformities Program is one of the few comprehensive centers in the country that focuses on the treatment of conditions, including pectus excavatum or sunken chest. Pediatric surgeon, Dr. Fizan Abdullah, is a world-renowned authority on minimally invasive surgery and chest wall deformities, and a leader in researching health services and surgical quality improvement. We talk with him today about advances in chest wall deformity, diagnosis, and treatment.

This is Precision: Perspectives on Children's Surgery, the podcast from Lurie Children's Hospital. I'm Scott Webb. Doctor, thanks for joining me today. We're going to talk about chest wall deformities, and I have to admit this is a new one for me, so it's great to have your expertise. So as we get rolling here, I want to have you tell us about the chest wall deformity program at Lurie Children's. What conditions do patients that you see have and generally what population do these conditions tend to affect?

Dr. Fizan Abdullah: Yes. Thank you so much for having me. Chest wall deformities are fairly common in children in the sense that we see them quite commonly. We're following a few thousand patients in the Chicago area with chest wall deformities. Most commonly, there's two types. There's one where the breast bone, which is right at the front and center of the chest, is pushed in and that's called a pectus excavatum or, alternatively, there's young people who have their breast bone which is pushed out, and that's called pectus carinatum. And both of these conditions are something that our center at Lurie Children's Hospital specializes in. And we have almost 30 people dedicated to this condition, including our inpatient and outpatient staff and operating room staff as well. So we're very committed to these young people to make sure that they can do well and feel better, not only about their chests, but see what we can do from a functional perspective, as well as sort of surgical and appearance perspective as well.

Scott Webb: That's really amazing again. It's why we have the experts on, because I had no idea that it affected so many children, no idea that you had so many team members working on this. And I do know and was reading that the conditions are more than just cosmetic. So maybe you can discuss how it really affects a child or adolescents, just general health, but also their sort of mental well-being.

Dr. Fizan Abdullah: Typically, the young people, when they have the breast bone that's pushed in, that's one that really has both a functional consequence as well as sort of an appearance consequence. Let's talk about the functional consequence first. Many people or many young teenagers who have pectus excavatum, that's the condition where the chest is pushed in, they can have occasional shortness of breath. They can have palpitations. They can sometimes not run as fast as their peers. And that's a pretty common thing. Although at that age, as we all may remember when maybe were 14 or 15 years old, the kids have a tremendous physiologic reserve.

So a lot of people can also overcome it. They're not all symptomatic, having shortness of breath or pain in that area. So the other side of this is exactly, as you said, the issues around their image, the image is certainly not as important as the functional outcome. Particularly in younger people, sometimes people think, "Oh, you're doing a correction of a pectus excavatum. It's cosmetic surgery." No, it's not really cosmetic surgery, especially when you think about it from a psychological development and confidence perspective. It's really important for young people to, you know, look and feel the best that they can. And in that sense, when we do the corrections, the primary reason we do it is for the functional outcome, so that they feel better, they have less shortness of breath, or they have less pain. But there's a definite major secondary benefit that they look better as well. Sometimes it can be so good that you don't even know that they have the condition anymore. So that's what's really exciting for us as a clinical care team, that when we can, you know, have those kinds of dramatic improvements, particularly for the kids whose chests are pushed in.

The other side of this is the condition I mentioned to you where the chest is pushed out, which is called pectus carinatum. And in those conditions, there's no limitation in terms of the actual volumetric space in the chest. There's enough space for the heart and lungs in those conditions where the chest is pushed out. So it is a little bit more cosmetic in the sense that we are focused on getting that breast bone pushed back into a normal position. And we primarily used to do surgery for that, 30, 40 years ago. But we really have now focused on brace therapy only. So we've got a team of orthotists and specialists who do this all the time, and we want to get those kids in braces so that we can help push the chest in to a more normal configuration.

Typically, in terms of ages, whenever this condition is being noticed, family should go and seek care and come see our specialty centers. We have obviously surgeons and advanced practice providers who see, as I mentioned, thousands of patients. But in terms of the typical average time that we start putting braces on is about eight years of age for the young girls and maybe age 10 for the boys. But we highly recommend, because we follow the conditions over time, that families, as soon as they notice that there's some type of chest deformities, they should come and see us at the Lurie Chest Deformities Center.

Scott Webb: Yeah, definitely. You can see why or how early diagnosis and treatment would be key. And you used the word exciting in there and I'm sure it's also rewarding. And I found with specialists like yourself, that there's an interesting path to where you are today, how you got where you are today. So maybe you could just tell us a little bit about your journey and how you got into this specialty.

Dr. Fizan Abdullah: Yeah. If you told me 20 years ago that I was going to be a specialist in chest deformities in children, I wouldn't have believed you, because I also have the privilege of serving as the head of the pediatric surgery division here.

Many times for young surgeons, we want to help them develop as very qualified and/or competent general pediatric surgeons. But many of them, particularly at Lurie Children's, have a subspecialty area. My subspecialty area, I fell into it during my time at Johns Hopkins. I was there for about a decade. And Dr. Alex Haller, who is one of the pioneers of pectus deformities and pectus surgery, was the former Chief of Pediatric Surgery at Johns Hopkins. And he is also the same Haller of the Haller index. That's the index that we use to measure the severity of pectus excavatum. Dr. Haller was there as an emeritus professor, so I had the privilege of working with him. And that was a very large practice that he had built at Johns Hopkins. But as a partner or two had left, I inherited that practice and it became subsequently my passion. So it has really been an extraordinary privilege to take care of those patients in Baltimore. And we were getting patients from all over the nation and the world, and we've been able to continue that here in Chicago.

Scott Webb: Yeah, you definitely have. So let's roll up our sleeves here a little bit and let's talk about the process for you in determining a treatment plan for patients. I'm sure maybe age is a factor when you're actually getting to see them the first time. But take us through this, how and what are the details, I guess, when we think about making those treatment plans. Take us through that a bit.

Dr. Fizan Abdullah: Yeah, let's focus on the condition where the chest is pushed in because that's the most common where surgery is needed, and that's pectus excavatum. For patients with pectus excavatum, we really want to see them as soon as a realization occurs, whether it's from the parents or the child themselves or from the pediatrician that there's some abnormality of the chest. So that could be even shortly after birth. Some of the kids do have it even at birth. Generally speaking, however, it gets more severe as the kids will get a little bit older. A child who has a mild pectus that might have been for the first 10 years of age was being followed and maybe hardly noticeable by parents, as soon as they hit the growth spurt, it's extremely common for that breast bone to drop further into the chest and for that pectus excavatum deformity to become more severe. And so that's why, for sure, we want to see them ideally before the growth spurt. But it's very common for families to come in when they're 11, 12, 13, saying that, "They're hitting the growth spurt and we really had noticed that this was mild before, but now it's become much more severe."

From a surgery perspective, we do the surgeries, currently our recommendation is around the 14th birthday. But in order for us to really get that all lined up, we really do want to see the families when they're 12 or 13 years of age.

Scott Webb: Yeah. And I know you're an expert in the surgery to treat pectus excavatum. So can you tell us what the procedure is like? Tell us about the procedure, maybe if you do it differently than other pediatric surgeons and what's the recovery like.

Dr. Fizan Abdullah: Yeah, there's more than 50 variations of the pectus excavatum correction surgery. The most common variation is what's called the modified Nuss procedure. And there's actually many subtypes of that. That is the type of procedure that I learned at John's Hopkins and further developed and have brought to Lurie Children's Hospital. The typical procedure is one where we custom mold a stainless steel bar for the young person. And then, we make two inch and a half incisions on each side of the chest in a minimally invasive way, past that bar in front of the heart and behind the breast bone. And if you want to see how that surgery's done, there's actually some beautiful animations and some clips of the actual surgery on YouTube. You just have to Google my name and pectus excavatum surgery and it should come up. But that's an opportunity for families to see the actual surgery. There's also 25 family stories, before and after pictures, et cetera, on my Lurie homepage. So that is something also that families have available. They found it very helpful to see the before and after pictures. There's also some videos of me examining the young people, also the families themselves, the parents, the kids talking about what it's like to go through pectus surgery. So we're very grateful to those 25 families who are willing to share their stories. And it's really helped those who haven't had the surgery yet really have the confidence to know what to expect.

Scott Webb: Yeah, I'm sure that before and after really helps. And maybe you can just talk a little bit also about just Lurie Children's in general. What makes your program, the Chest Wall Deformities Program so unique?

Dr. Fizan Abdullah: Yeah, I think the Lurie Children's Chest Wall Deformities Program is one where we have a dedicated group of specialists, including not just surgeons, but advanced practice providers, orthotists, physical therapists. We work in partnership with our cardiologists and pulmonary doctors to really optimize the care of these kids. Many of them that have pectus excavatum may not need surgery and some do, so we have really the best diagnostic team that can help manage these patients. So I think that's really the opportunity and the privilege that we have in taking care of these families and these young people. And really, it's about maximizing the potential of every young person. That's what I want for my kids and that's what I'd want for every child that's in the pectus program.

Scott Webb: Yeah, I was going to ask you a follow up with your philosophy of care. But obviously, one of the things probably at the top of the list is really customizing the treatment and the program to the actual person, to the child, to the adolescent, to the respective families, right?

Dr. Fizan Abdullah: Absolutely. Some families are much more concerned about a functional outcome versus the appearance. And it's natural. Some of the younger individuals are more concerned about the appearance. I think that is not cosmetic surgery in those situations because it's really about their self-image and a healthy development of their psyche. And so we really go to great pains to do whatever we can to give them the best cosmetic result, although the primary purpose is to really improve the functional outcome.

Scott Webb: I know you've got a PhD in addition to the MD, so that's obviously very ambitious of you. I'd like you to talk about that a little bit, how having that PhD really enhances your care that you provide.

Dr. Fizan Abdullah: Yeah. I mean, I had the privilege of having studied the scientific method during my PhD studies. And that really allows me to think about not only those individual patients, of course, when it comes to individual patient care, we want to get the very best outcome for every single individual patient. But when we think about a health system, we have to think that there's different strategies that need to be developed and implemented in order to assure perfect outcomes for all of our patients. And so to have that formal training in the scientific method, as well as clinical trials experience really helps me as we think about new innovations to really help our patients.

One of the major innovations that we've been working on is the use of wearable sensors. And we're actually using Fitbits probably most commonly, and we're replacing them on our pectus patients. And we're able to see that after their procedures, we can follow their heart rates, their step counts and see if someone's not on the normal trajectory pattern. We can potentially utilize these technologies to contact them in a more proactive way. Because right now, the way the health system is set up, you get a discharge summary and you get a phone number and you say, "Good luck." And if there's a problem, call us. But really the future of healthcare is where we're in a much more proactive way going to be monitoring our patients.

So we are definitely doing a lot of work right now at Lurie Children's. In terms of if you get a pectus surgery, you're going to get a wearable device. We're not quite there yet that we have the clinical care teams that can respond to the data real time, but we definitely are analyzing it in a, you know, retrospective way and are making the case that, in the future, we need to change our model of care so that in a real time basis, we can engage with families and let them know, "We notice that your child is not doing the expected amount of step counts. Is there a problem with the wound? Is there a problem with a pneumonia or some other issue that we would need to help identify and track them? Then otherwise, you know, coming to the emergency room or calling in and saying, you know, "In the last few days we noticed that things weren't going well," so we want to be much more proactive about the care of children.

Scott Webb: I mean, that just brings a huge smile to my face and the thought that we're so close to being able to track patients in real time. I mean, it really makes you optimistic for the future, I'm sure.

Dr. Fizan Abdullah: Yeah, I know, it's incredibly exciting. I think all of us could recognize that if my child had surgery and the clinical care team was monitoring them beyond sort of the immediate effects that, yes, we'd be able to reach out. It also gives me comfort and peace and, you know, a peace of mind that knowing that the clinical care team is keeping an eye on my child. So I think that's also something that will be helpful. But the realities of this are that it's an overwhelming amount of data. And the amazing times that we live in, the only way we can really have these systems work is using artificial intelligence. And this is where you're not going to have doctors necessarily or nurses looking at that data, but we can absolutely. We've already done some of this preliminary work where we can absolutely train the computer to say, "You know what? Out of all the vital signs. This one doesn't look good and, you know, we're monitoring 50 children. These two are the ones that we need to pay attention to and generate alerts for the clinicians." Because yes, of course, ultimately the clinicians, the nurses and the doctors need to look at those children. But right now, one of the major challenges is that the amount of data that's coming off of these devices is just extraordinary. So to really use the data in the best possible way, we've got to utilize artificial intelligence to do this.

Scott Webb: Yeah. And as you're discussing here today, being able to process all that data, all that information in real time and be able to track patients in real time, it is just really amazing. And maybe have you discuss what were things like 10 years ago, 20 years ago. I'm sure the field has advanced so much from when you were at Johns Hopkins to where you are today, right?

Dr. Fizan Abdullah: Absolutely. And I think the really exciting thing about the next decade, I think it's really about how we are going to incorporate these amazing technologies. I think we all recognize that the mobile phone and the absolute ubiquitousness of technology all around us. But as of today, it's really not been incorporated in a major way in terms of healthcare and clinical decision-making.

Yes, you can make an appointment more conveniently. But we've not really integrated into our clinical decision-making. So to have that from a clinical perspective, what's exciting about that is that this kind of work where, as you said in the past, even if we had the technology 10, 15, 20 years ago to monitor patients real time, we probably did, it would've taken dozens of doctors and nurses, you know, and the value proposition just wouldn't have been there. But now with these automated algorithms, you can get off the shelf artificial intelligence algorithms that can help us and we can train them very quickly. So that's what's exciting, is that it's going to allow this technology to be implemented. And, you know, we are then going to be able to have line of sight on, you know, hopefully large numbers of patients to really help them and know who are the patients that need to come to the emergency room sooner and who are the ones that we don't need to come to reassure you, because many patients come to the emergency room because just of a lack of education or lack of knowledge. And when I say education, I mean a lack of education, both in what they're supposed to be doing and lack of education around their clinical care, like how are they supposed to handle the dressing, is a little bit of bleeding okay? And they just get understandably anxious, right? They're not doctors are nurses and you see a little bit of bleeding on your child's wound after the surgery, the instinct is to rush into the emergency room. So having a line of sight, whether that's through telemedicine in addition to wearable technologies, the entire model of care is going to change in the next decade.

Scott Webb: And I love that you're using that expression line of sight as an old-timey radio guy, we think about FM radio waves and line of sight. Boy, you're speaking my language, doctor. I always like to ask, we get experts, we're fortunate enough to get experts like yourself on where do you turn or who do you turn to if and when you have questions yourself?

Dr. Fizan Abdullah: If you're talking about the pectus patients, I'm very lucky. I have another partner who does a lot of this surgery. I also have the privilege of training him, but he's really fantastic, so I turn to him. Also, there's a national network of pediatric surgeons who we are always having discussions of difficult cases and that's another place where we can turn. But definitely, you know, clinical care is a collaborative sport. But the old sort of model of where the expert surgeon made all the decisions is I think falling out of vogue now. It's really about collaborative care. My advanced practice nurses, they see perhaps more patients than I do, because they work with both of the surgeons that are doing pectus surgery. So I think it's much more collaboration. It's much more, "Let's come to the best composite care model we can for a specific patient and plan for a patient."

Scott Webb: So doctor, you've talked about the future or maybe the present, but hopefully the future about wearables. What else are you doing? What other types of research are you doing at the Stanley Manne Children's Research Institute?

Dr. Fizan Abdullah: We've also deployed a technology where we can take three-dimensional images of the chests of these young people who have this condition and we can measure off of it. I used to explain it to the families that it's like taking a picture and creating a wax museum figure at Madame Tussauds and all the young people had no idea what I was talking about. So now, I explain it and I tell them it's like having an avatar created of your entire body. Every time you come, we'd create an avatar of your body through using a white light, a flashlight we shine at you and the computer can generate these amazing images. And this avatar gets created and you get an avatar created this time. And then, you hit your growth spurt and then you come next time, then we create an avatar. And then, we can see on the avatar how far in your chest went further. Or even the most fun scenario is when we do the surgery and we do the correction and you can see the pre-surgery avatar. And then, we do the surgical correction and then you can see how much the chest came out. And it's like a three-dimensional image. You can spin it around. You can look at that graphic image. So that's really fun. So no wax museum figure, it's all done digitally now.

Scott Webb: It's all digital avatars. Well, this has been such a pleasure. I just love learning from experts. It's so amazing. And the future is just so bright for these patients. As we finish here today, what inspires you the most about your work?

Dr. Fizan Abdullah: Well, I think it's really seeing the smiles on the young people's faces and the families when they've come to us with what they naturally see as a challenge, especially when they're having shortness of breath or they're having pain and they can't keep up with their friends. And then, seeing them a year later after they've been through the evaluation, they've had the surgery they've recovered and the stories that we hear, that they are just doing so much better. They're doing better in sports. They're doing better in terms of their self-image and confidence. And to see those young people really come to their maximum potential and come to fruition. It's just so exciting and it's such a privilege for me.

Scott Webb: Yeah. Well, this has been a privilege for me. You know, I get to talk to these experts, all you experts at Lurie Children's and find out about how you are changing the lives of children and adolescents and families, and it's just such a pleasure. So thank you so much. You stay well.

Dr. Fizan Abdullah: Thank you so much. I really appreciated the opportunity.

Scott Webb: For more information, go to luriechildrens.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for additional topics of interest. This is Precision: Perspectives on Children's Surgery, the podcast from Lurie Children's Hospital. I'm Scott Webb. Stay well.