It is the most common among chest wall deformities, that is, deformities. It is characterized by the fact that the rib cage forms a depression inward. It occurs in one of every 300-400 live births. It occurs four times more often in men than in women. 37 Percent of patients also have this disease in their family history. With an advanced displacement of the chest wall to the back, dimpling can occur, especially in the anterior wall of the right heart ventricle. In addition, in cases of advanced collapse, the heart often shifts to the left.

 

 

It is caused by an abnormal growth of the costal cartilage junction between the rib and the sternum (Decapitation board). Although the collapse is caused by the overgrowth of these cartilaginous ribs, it is not known exactly what causes it. The ribs consist of two parts: the bone rib and the cartilage rib. The cartilaginous part of the rib, which grows unevenly, pulls the iman board to the back.

 

 

Symptoms, although the disease occurs in childhood, typically become apparent during the growth phase and adolescence. Whether pectus excavatum can cause significant symptoms and signs is still a matter of debate. Symptoms can be identified by a health professional based on the patient's complaints. The presence of symptoms in patients varies. Chest and back pain are the most common and occur in almost every patient. These are pains originating from the November musculoskeletal system. Another common complaint is a history of shortness of breath, especially due to exertion. Poor posture is also a factor in the development of such pain and shortness of breath. The most common symptoms can be listed as follows:

 

 

It usually occurs in the chest and back area. It tends to come and go and can get worse after certain activities or exercises. It can be exacerbated during periods of excessive growth. Poor posture, i.e. posture disorders, can also trigger pain. Individuals usually give the degree of their pain between 1 and 10 points above Dec. 8.

 

 

The feeling of shortness of breath and shortness of breath is usually experienced and worsens after some activities and exercises that involve effort. Most doctors are of the opinion that there is a significant relationship between the Decadence of the chest wall and symptoms such as decreased lung function or shortness of breath. However, when lung or respiratory function is measured (spirometry), at least in simple tests, the results usually appear normal in the majority of patients. However, measurements made in patients who were monitored, especially while exercising, showed the relationship between shortness of breath with exertion and a decrease in pulmonary reserve Dec. It has also been observed that exercise tolerance increases in patients after surgical correction.

 

 

In severe forms, an increase in complaints of heart palpitations is observed. In addition, rhythm disturbances or murmurs in the heart can be detected. The inward depression in the chest wall leads to a physical displacement of the heart, which is located behind the sternum and slightly to the left of it, which can cause the symptoms mentioned. In severe forms, it can even affect heart function. Some studies have shown that corrective surgeries can improve heart function.

 

 

In severe cases, syncope (short-term fainting or clouding of consciousness) may occur due to shortness of breath, although rarely. It can occur in situations of exercise or exertion. It is believed that it is caused by a disruption in blood flow due to the pressure of the collapsed sternum on the heart.

 

 

The psychological impact of the abnormal appearance of the chest wall is the most important symptom that pectus excavatum patients complain of. Serious lack of self-confidence in the patient, going overboard, etc. such as withdrawal from many activities, especially in adolescence, there may be negative psychological effects caused by physical appearance. This condition can even become an obstacle to the patient's socialization.

 

 

The diagnosis of pectus excavatum is actually made by the examination and complaints of the patient, which doctors call clinical. Usually, a physical examination by a doctor who knows pectus deformities is sufficient to diagnose. A specific blood test, etc. there is no. However, sometimes with radiological removal (X-ray), it can be helpful in determining the severity of the disease and detecting other related problems in the spine, such as scoliosis. The most useful radiological test for problems that may have caused on the heart is chest tomography. In this way, in addition to the displacement of the heart, the degree of sternal rotation caused by pectus asymmetry (the severity of the depression) can be examined more precisely. This examination is especially important for patients who are scheduled for surgery. MRI is an imaging technique that can be used in children without radiation anxiety. In addition, other tests such as echocardiography (evaluation of the heart by ultrasound) and a lung function test are not necessary unless the symptoms are severe or another underlying cause is suspected, such as “Marfan syndrome”.

 

Pectus Excavatum can also be accompanied by other diseases. In cases with Marfan syndrome, the collapse is more severe. In particular, boys with scoliosis should also be evaluated from this point of view. Apart from this, although rarely, Tetralogy of Fallot (TOF; a hereditary heart disease) and Mitral Valve Prolapse (mitral valve prolapse) may accompany it. Pectus excavatum is actually more common in those with November musculoskeletal disease and developmental abnormalities. It can also be seen in combination with connective tissue diseases (Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta, and homocystinuria). It is also common in those with Down syndrome (mongolism), congenital heart disease (TOF, etc.), and congenital diaphragmatic hernia. In 5 to 26 percent of patients, it is accompanied by lateral curvature of the spine (scoliosis) and hunchback (kyphoscoliosis).

 

 

 

Surgery is at the forefront of the treatment of pectus excavatum. However, in a selected group of patients, “Vacuum Bell” treatment can also give satisfactory results. The patient is monitored using this device regularly for 3 to 12 months. However, before deciding on Vacuum Bell treatment, the degree of collapse should be determined and the patient should start this treatment if the doctor is suitable for a non-surgical method. Vacuum application is a procedure that can be performed in people under the age of 17, while the rib cage is still flexible.In the process, the vacuum provides improvement by suction (negative pressure) after being placed on top of the existing pit. The application is carried out twice a day, one hour in the morning and evening. The best results are provided in cases of mild and moderate shoemaker's chest. A study conducted in America has shown that the best results are obtained at the age of 12-13 years. When regular application is made, the result is obtained around 3-6 months. It may be necessary to continue the application for up to 9-12 months for a definite result. Vacuum application is a form of treatment that requires patience and stability.

 

 

In surgery, on the other hand, two methods are widely preferred. One is the so-called ”Modified Ravitch" open surgery. In open surgery, a vertical or horizontal incision is required in the anterior chest wall. After the muscles located under the breast tissue are removed, some removal of the cartilage parts of the ribs located on both sides of the iman board and November correction of the sternum bone is performed. In addition, various plaques can also be applied over or under the sternum bone in order to prevent the development of re-collapse. Open surgery takes longer and there is a scar on the anterior chest wall.After cartilage removal, there may be some deterioration in respiratory function due to narrowing of the rib cage. After open surgery, the chest wall weakens, its stability and strength decrease for a period that cannot be considered short.

 

 

The other surgical method has been used in our country since 2005 by Prof. Dr. It is the “Nuss Procedure”, which is a closed surgical method successfully applied by Mustafa Yuksel. It is a method of lifting the ribs and cartilage forward by supporting the back of the depression on the faith board with a metal bar without the need to cut or divide. Before this method, pectusexcavatum correction surgeries involved a long stay in the hospital, which led to long periods of surgery and a lengthening of the recovery period. in 1998, the American surgeon Dr. With the new technique introduced by Donald Nuss to the medical world, it was possible to treat patients in a short time. The Nuss operation, in appropriate cases according to the operation method is much less invasive thoracoscopic classic Ravitch at least 4 hours, finish in a short amount of time 15-20 minutes, the final aesthetic to be after surgery, the patient should be preferred to increase the comfort of discharge time and fast approach.

 

Prof. Dr. Hundreds of patients have been treated with this method by Mustafa Yuksel. In order to correct the collapse in the chest wall during surgery, a nickel-chromium-mixed steel bar (or a specially manufactured titanium bar for patients with allergies) is inserted under the patient's skin with closed surgery.

 

The procedure followed during the Nuss method is briefly as follows:

 

-The patient is laid on his back under general anesthesia.

 

-The deepest and highest point of the hollow in the chest is marked on both sides.

 

-2-inch incisions are made at a distance close to the points marked on the sides.

 

- Height determination is made with the aluminum model of the metal bar to be placed.

 

-The model is shaped and the metal bar is shaped with a bending tool by looking at this model.

 

-The thoracoscope is inserted into the chest cavity through a small incision made in the armpit line on the right side.

 

-The tunnel opener inserted into the chest cavity through the incision on the right is extended to the left chest cavity through the tunnel opened between the heart membrane with the belief board (sternum) at the deepest point of the Decapitation and is removed out of the incision made on the left.

 

-The guide rope connected to the end of the tunnel opener is retracted and the end is allowed to protrude through the incision on the right.