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about Funnel Chest, Operations, Risks, Prospects of success
What resources should a hospital offer?
Corrective surgery with elevation of the chest wall should only be carried out by hospitals with extensive experience - if possible with a number of different treatment methods - and a high volume of operations annually, with correspondingly experienced surgeons. Only then is the procedure relatively risk-free, with a high chance of a successful outcome.
Other requirements include experience with pre- and post-operative care, skilled physiotherapists and nurses, and an intensive care unit available if needed.
Bearing in mind the remote possibility of complications such as injury to the heart, especially in minimally invasive procedures, surgery should only be carried out in centres which have facilities for cardiothoracic surgery on site.
How many operations do you carry out each year?
In Erlangen more than 6000 corrective operations on the chest wall have been carried out altogether. In 2002 there were 101 major chest wall operations, and in 2003 there were 117. In addition there were about the same number of more minor operations on the chest wall, such as to remove metalwork or smooth out superficial irregularities of cartilage or bone.
How will the operation be done?
Which methods of treatment are there?
When is treatment necessary?
What risks are involved in treatment?
In specialised hospitals, chest wall surgery is in general a routine low-risk procedure. In spite of the greatest care being taken, with any of the surgical techniques complications can occasionally arise which call for further treatment. In particular, these can include:
Injuries to the organs of the chest (such as the heart and lungs) and to the great vessels. These hardly ever occur using conventional techniques. The risk is increased when deformity is extensive (such as after heart surgery or in re-operation after relapse) and also in minimally invasive techniques where the breastbone is not exposed in an open operation.
Nerve injuries, persistent pain. Wound pain should last a few days at most after the operation. Tiny nerve branches are severed during surgery, and this usually causes a long-lasting or permanent numbness or reduction of sensitivity to pain and touch adjacent to the operation scar, which is seldom troublesome. Rarely, persistent nerve pain can occur because of damage to one of the nerves running between the ribs or because of the pressure of a metal plate next to it (intercostal neuralgia). This risk is increased in minimally invasive surgery.
Inflammation of the bone surface (periostitis). Very uncommonly, mechanical irritation, such as rubbing against a metal plate, of the surface of the rib or costal cartilage can cause a fluid collection, pain, withering of a fragment of rib or the formation of new connective tissue or bone.
Pressure damage to nerves and soft tissues because of the positioning needed during the operation (very rare). This usually recovers within a few weeks of surgery and seldom leaves any lasting symptoms (e.g. impaired sensation) or troublesome scars. The same is true of skin damage from disinfectant or electrical current.
Gas in the soft tissues (surgical emphysema) and shoulder pain usually require no special treatment and disappear within a few days.
Back pain and muscle pain in the weeks following the operation are mostly caused by tension and unaccustomed posture. They require relaxation exercises and physiotherapy.
Profuse bleeding at the time of the procedure or in the first few days after surgery. A transfusion of blood or blood components is seldom necessary. Transfusion can, extremely rarely, transmit disease (e.g. hepatitis viruses causing inflammation of the liver, or HIV leading to AIDS). Although it has never been reported in humans, the transmission of spongiform encephalopathy in blood cannot entirely be ruled out.
Collections of blood or fluid can appear in the pleural space, days (rarely weeks) after surgery. These require tapping or suction drainage.
Pneumothorax. If air enters the pleural space and the lung collapses, suction drainage can be necessary.
Delayed wound healing, scars. Breakdown of the edges of the wound, poor circulation of blood to soft tissues or infection can significantly delay healing, by days or weeks. If scarring is troublesome, corrective surgery is usually needed. Rarely - in particular when implants have been used - abscesses and persistent fistulae can occur, which often only heal when the implant is removed.
Excessive scar tissue (keloid), especially in predisposed patients. Treatment is lengthy, and the outcome can often be disappointing.
Mediastinitis. In the past, serious infections could occur beneath the breastbone, which needed to be treated with drainage, antibiotics and intensive care. For many years this complication has no longer been seen.
Side-effects of foreign material. Particularly in the case of cosmetic surgery, ask which material (e.g. silicone) is to be implanted and what side-effects (e.g. risk of cancer) and long-term effects (e.g. shift of the implant) can occur.
Allergy to metals can cause inflammatory reactions, which may mean the metal needs to be removed prematurely. In known cases of nickel allergy, nickel-free alloys can be used, such as alloys of titanium.
Tearing or breaking of implanted material (such as sutures or metal components). This rare event can occur if excessive loading on the body occurs too soon after surgery (e.g. fall, collision, sporting injury, weight training) and can lead to a new chest wall deformity.
Skin and soft tissue damage from injection sites (abscess, breakdown of tissue, nerve and vein inflammation). This rare complication can cause long-term problems (scarring, pain, loss of function).
False joints (pseudarthroses). If ribs are divided and their healing is disturbed, joint-like connections can form between the fragments, which are not especially stable. These can cause pain and increase the risk of recurrent deformity.
Recurrence. The re-emergence of a chest wall deformity - months or years later - cannot be completely guaranteed against, whatever the surgical method.
When will my insurance organisation pay for an operation?
In Germany insurers will only pay for operations with a clinical indication, and not for purely cosmetic procedures.
What pre-operative investigations are needed?
Lung function test and an ECG exercise test. And the usual medical examination to check fitness for surgery.
Is a blood transfusion necessary?
A blood transfusion is generally very seldom necessary (but this depends on the method of surgery).
How long must I wait after the operation, before I can take part in sport?
This depends on the method of surgery. Usually fitness training can begin immediately, and a return to full activity is possible for children after 6-8 weeks and for adults after 12 weeks.
At what age is an operation advisable?
Usually not until after puberty; in exceptional cases during childhood (in severe cases where there is significant encroachment on the organs of the chest).
Are repeated procedures necessary?
This depends on the method. The recurrence rate in long-term follow-up (five years from operation) should not exceed 2%.
What possible problems can be expected during and after an operation? -->
What are the prospects of success in chest wall corrective surgery?
These depend on the method and on subsequent treatment (keeping to time limits, avoiding strenuous activity too early).
Using the Erlangen method, about 1-2% of patients can expect that the chest wall elevated in the operation will subsequently sink to its original depth and require a second operation.
Using some other methods, recurrence rates of up to 20% are reported.
