Surgeons unlock secret to treating pigeon chest

Mackenzie Cave, a bright 17-year-old who loves sports and science, developed a bony protrusion in his chest just after he turned 10. The protrusion — a deformity that affects one out of every 1,500 children — is known as pectus carinatum, but is often referred to as “pigeon chest.”

Mackenzie Cave, 17, with mother Sue O’Neill, was the first patient in Canada to undergo a new surgical procedure that treats a bony chest protrusion known as pectus carinatum. Dario Ayala, Montreal Gazette Photo

Aaron Derfel, Montreal Gazette August 20, 2014

Mackenzie struggled to adapt to his chest anomaly. He hunched his posture to hide the protrusion. He wore loose T-shirts.

But two years ago, as Mackenzie was entering his science class, his teacher turned to him and asked him what he was hiding on his chest. When he told her it was nothing, she insisted on seeing under his shirt.

“It was very embarrassing,” he recalled. “That’s when I made the decision to do something about it.”

On July 10, Mackenzie underwent surgery at the Montreal Children’s Hospital to correct the chest anomaly, becoming the first patient in Canada to benefit from a new “minimally invasive” procedure that avoids a long, unsightly chest scar while reducing post-operative complications.

“I feel great now,” he said on Wednesday. “I’m extremely happy with the surgery.”

Mackenzie was wearing a T-shirt with the iconic image of Muhammad Ali standing over a prostrate Sonny Liston. Unlike his old shirts, this one wasn’t overly loose.

“It’s barely noticeable now,” he said of his chest bump.

Until now, individuals with pectus carinatum faced a difficult choice: either wear a cumbersome chest brace for years, or undergo invasive surgery with a risk of additional internal scarring that could make the chest wall stop growing. Although improvements have been made with a new “dynamic” brace that is adjustable, it doesn’t work on up to 15 per cent of patients.

Sherif Emil, a visionary surgeon at the Montreal Children’s and co-director of the Chest Wall Anomalies Clinic at the Shriners Hospital, had heard of an innovative surgical procedure in the United States and decided to try it in Québec. He contacted Robert Kelly, a surgeon in Norfolk, Va., who agreed to assist him in operating on Mackenzie and another child.

Reverse Nuss procedure for pectus carinatum. Lungs and pleural spaces are clear. Cardiomediastinal contour is normal. No hardware failure or evidence of displaced rib fractures. Radiopaedia

The new technique is called the reverse Nuss procedure. The traditional Nuss technique is intended for patients with another anomaly — pectus excavatum, or sunken chest — and involves inserting a metal rod in the chest, behind the sternum, pushing the chest outward.

With the reverse Nuss, surgeons insert a rod over the sternum, pushing it in. Unlike the long incisions of standard surgery, two small “keyhole” cuts are made on either side of the chest, through which the rod is threaded.

“There’s a lot of carpentry and hardware involved,” Emil explained, noting that special wires are needed in addition to the rod — and both required Health Canada’s approval.

Emil said he expects that four to five patients a year will undergo the reverse Nuss procedure at the Montreal Children’s, with the support of the multidisciplinary care team at the Shriners Hospital.

“We’re envisioning that 10 years from now, patients all around the country with this anomaly will benefit from this technique,” Emil added.

In two to three years, the rod will be removed from Mackenzie’s chest. “I’ll have a couple of scars left, which will make for a cool story,” he said, grinning.

Source Montreal Gazette

Initial results with minimally invasive repair of pectus carinatum, Kálmán A, J Thorac Cardiovasc Surg. 2009 Aug;138(2):434-8. doi: 10.1016/j.jtcvs.2008.12.032. Epub 2009 Mar 9.

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