Pre-operative considerations
Patients and their families should be fully informed of their expectations of the surgical outcome before surgery, and they should be informed that although surgery of a cosmetic nature may not always achieve the “perfectly normal or perfect” results they expect, patient satisfaction after surgery is still high and the complication rate is low.
1. Age
Many surgeons used to believe that funnel chests should be treated early to promote normal lung development, however, most now agree that surgery should be performed in childhood or before adolescence.
Minimally invasive surgery has been successfully used in patients from 1 year to over 50 years of age, with the ideal age being prepubertal because the thorax is still more ductile at this age, with a short recovery time and low recurrence rate due to the fixed position of the support plate during the rapidly developing adolescent years.
Good results and short recovery times have also been achieved in children before the age of 8 years, but there is a potential risk of recurrence because the support plate has been removed before puberty. However, if significant heart and/or lung compression is present, early surgery is also appropriate. The parent(s) should be informed that a second, longer plate may need to be placed at the time of removal of the first one, or that in the event of recurrence during adolescence, the chance of recurrence is approximately 5% and the patient may use a second plate.
Up to the age of 10 years, minimally invasive surgery was thought to be appropriate only for prepubertal children, but experience has shown that post-pubertal patients continue to tolerate the procedure well, and good results have been achieved in patients between 30 and 50 years of age. Over 50% of older patients require two or more plates.
We believe that the appropriate age for surgical correction is after 10 years of age, when the plates need to be left in place for 2-3 years, which coincides with a period of rapid growth and further ossification of the thorax. The development of funnel chest is the fastest and most obvious during adolescence, so if surgery is taken too early, it may recur during adolescence.
2.Surgical indications
Although in practice most patients are referred after an evaluation, only half of the patients who visit the author’s unit are recommended for surgical treatment. Therefore, as Willis Potts points out, “our attitude toward surgical correction is somewhere between surgery and no surgery for most children with funnel chest”.
Surgery is indicated if the patient has at least two of the following conditions.
(1) they have symptoms;
(ii) the depression is further aggravated;
(iii) Paradoxical thoracic motion during deep inspiration;
④Haller’s index is greater than 3, 25 on chest CT film;
⑤ Pulmonary function tests suggest significant restrictive ventilation disorders;
⑥Mitral valve prolapse, bundle branch block, or other heart disease caused by cardiac compression;
(vii) Failure of previous treatment;
(viii) Significant psychological impact.
Indications for surgery: at least two of the following
symptomatic
persistent worsening of the deformity
Paradoxical respiratory movements of the chest wall
Haller index >3, 25
Cardiac compression, displacement, arrhythmia
Compression of the lungs
Pulmonary function tests show significant restrictive lung disease
Mitral valve prolapse
Any cardiac disease secondary to cardiac compression
Significant psychological effects
Abnormal cardiopulmonary function
Failure of other treatments