Compassionate Care for Chest Wall Malformations in Children

Southwest Florida’s white-sand beaches, uninhabited islands, and exotic wildlife make our area a dream destination for many, including for Pediatric Surgeon Dr. Andre Hebra.

In April, Dr. Hebra relocated from Central Florida to join Lee Health and Golisano Children’s Hospital of Southwest Florida. But Dr. Hebra has much more in mind than just enjoying our natural wonders.

Dr. Hebra has a vision to make the children’s hospital a destination center for children born with congenital chest wall malformations such as pectus excavatum, the most common type of congenital chest wall deformity.

“The congenital chest wall malformation program allows us to optimize care for children with chest wall anomalies,” says Dr. Hebra, who is board-certified in general surgery, pediatric surgery, and critical care. “The condition can create functional problems for children, which can lead to difficulty exercising, breathing, and can even cause cardiac problems.”

What is pectus excavatum?

Pectus excavatum, a Latin term for “hollowed chest,” is an abnormal development of the rib cage that gives the chest a caved-in or sunken appearance. The condition develops when there’s abnormal growth of bone and cartilage connected to the breastbone (sternum). This causes the sternum to grow inward and even rotate – displacing the heart and lungs, Dr. Hebra explains.

“As a result, there is a depression in the center of the chest over the sternum, which may be very deep and disfiguring,” he adds. “If the condition is severe, the heart and lungs can be affected. Also, the way the chest looks may cause significant psychosocial and emotional problems.”

Dr. Hebra notes that pectus excavatum may not be obvious in the first few years of a child’s life. Cases are often found in the early teenage years. The exact cause of the condition, which affects about one in 400 children each year, is unknown, but it seems to be genetic.

For more than 25 years, Dr. Hebra has centered his practice around the management and development of innovative treatments for pectus excavatum and other congenital chest malformations. Formerly, Chief Medical Officer of Nemours Children’s Hospital in Orlando, he has pioneered research related to chest abnormality treatments, optimizing care for children in the process, especially those with pectus excavatum.

“Generally, surgery is advised if there are cardiopulmonary health problems, such as trouble breathing with exertion, ”Dr. Hebra says. “Surgery may also be done to improve the appearance of the chest.”

Dr. Hebra says the technical complexity of surgical intervention is quite significant, which demands that patients receive leading-edge, safe, surgical intervention to ensure the best possible outcome.

“The team here has extensive experience and knowledge of how to treat chest wall malformations. As a result, our expertise can minimize the risk of complications, which sometimes can be life-threatening.”

Symptoms of pectus excavatum include:

• Problems tolerating exercise
• Limitations with certain physical activities
• Tiredness
• Chest pain
• A rapid heartbeat or heart palpitations
• Frequent respiratory infections
• Coughing or wheezing

How is pectus excavatum diagnosed?

Dr. Hebra and his team diagnose pectus excavatum based on a physical exam and a child's medical history. If needed, other tests might be ordered, such as:

• Computed tomography (CT) scan and/or a chest MRI to see the severity and degree of compression on the heart and lungs
• Echocardiogram to test heart function
• Pulmonary function tests to check lung volume
• Exercise stress testing to measure exercise tolerance

How is pectus excavatum treated?

According to Dr. Hebra, children may benefit from various types of treatments such as physical therapy and bracing. Selective patients will benefit from minimally invasive surgery, which is considered an elective procedure. He says children with mild pectus excavatum usually don’t require treatment if it doesn’t affect their breathing or their appearance doesn’t bother them.

“But if the condition affects a child’s self-image and makes playing sports or exercising difficult, surgical treatment can improve their physical and emotional well-being,” Dr. Hebra says.

A new non-surgical approach for mild pectus excavatum is an at-home treatment that involves a custom-made vacuum bell device that is applied to the child’s chest. Dr. Hebra has made this available at Golisano now. The bell device, connected to a pump that sucks the air out of it, creates a vacuum that pulls the chest and breastbone forward. Eventually, the chest wall will reshape and remain forward without the use of the bell device.

The Nuss procedure: A revolutionary option

For children who require surgical intervention to correct pectus excavatum, Dr. Hebra’s program offers the innovative minimally invasive procedure called the Nuss procedure.

“The Nuss procedure has revolutionized the way we manage the condition,” Dr. Hebra says. “Before it became the gold standard, 20 years ago, chest wall repair in children was a highly invasive procedure in which the chest was opened through the front and rib and cartilage had to be resected. The open surgery was often a long and complex operation that left the patient with a noticeable, unappealing scar across the chest.”

The minimally invasive Nuss procedure has changed all that, Dr. Hebra says. Using video-assisted, camera-aided thoracoscopic surgery, the surgeon makes small incisions and places an internal curved metal strut that is specially shaped to fit and correct the patient’s specific type of chest caved-in deformity. The bar pushes out the sternum and ribs, allowing for natural reshaping without cutting or breaking any bone and cartilage structures. A stabilizer bar is added to keep it in place. In 2-3 years, the chest is permanently reshaped, and the bars are removed.

The Nuss procedure is recommended for children age 12 and older. For severe cases, it might be necessary to operate even at younger ages.

“Most kids and teens who have the surgery do extremely well and are happy with the results and the positive impact on quality of life,” Dr. Hebra says.

Reducing pain

In keeping with the leading-edge technology of the congenital chest wall malformation program, Dr. Hebra says he’s introduced the use of cryoablation therapy for chest wall repair surgeries. The technique helps reduce patient pain, accelerate post-operative recovery, and minimize the risks associated with narcotics to manage post-operative pain.

“Although the Nuss procedure is minimally invasive, the technique involves the bending of ribs and the sternum, which typically causes the patient significant pain.”

Dr. Hebra says before the use of cryoablation therapy, post-operative pain typically was managed with significant use of narcotics and controlled substances.

“The challenges with narcotic management are its possible side effects and the risk of the patient developing narcotic dependency,” Dr. Hebra notes. “Cryoablation therapy helps minimizes those risks.”

In cryoablation, Dr. Hebra uses liquid nitrogen to freeze the nerves of the chest wall during surgery, numbing them and dramatically reducing the level of pain patients experience after surgery.

“Post-operative management becomes safer and much better,” Dr. Hebra says. “Recoveries are much faster with less pain. The use of narcotics is lessened, and most importantly, five-to-seven-day hospital stays often become half that. Kids can go home sooner and resume normal activities more quickly because they have less pain.”

---

Golisano Children’s Hospital features a multidisciplinary team of pediatric specialists like Dr. Hebra, who can perform a comprehensive evaluation of your child for treatment and management of congenital chest wall malformations.

Call 239-343-7474 for a consultation or to make an appointment with the pediatric experts at Golisano Children’s Hospital of Southwest Florida.