Anthropometric Index for Quantitative Assessment of Pectus Excavatum*

Jornal Brasileiro de Pneumologia 30(6) - Nov/Dez de 2004 Anthropometric index for quantitative assessment of pectus excavatum* EDUARDO BALDASSARI REBEIS(TE SBCT), MARCOS NAOYUKI SAMANO, CARLOS TADEU DOS SANTOS DIAS, ÂNGELO FERNANDEZ(TE SBCT), JOSÉ RIBAS MILANEZ DE CAMPOS(TE SBCT), FÁBIO BISCEGLI JATENE(TE SBCT), SÉRGIO ALMEIDA DE OLIVEIRA (TE SBCT) Background: Pectus excavatum is characterized by concave growth of costal cartilage and depression of the lower sternum. Clinical means of classifying these malformations are few and difficult to apply. Objective: To devise clinical tools for quantifying the deformity and comparing preoperative and postoperative findings. Method: A total of 10 pectus excavatum patients who underwent surgery in which the modified Robicsek technique was used by the Thoracic Surgery Group of the Hospital das Clínicas of the University of São Paulo School of Medicine, were clinically and radiologically evaluated in the preoperative and postoperative periods. Ten control individuals, presenting no thoracic or radiological abnormalities, were submitted to identical evaluations. Deformities at the sternum notch level and at the point of maximum deformity were assessed using the anthropometric index and the Haller index. Results: Multivariate analysis of anthropometric index means revealed significant differences between preoperative and control values and between preoperative and postoperative values, as well as a non- significant difference between postoperative and control values. The same results were obtained when Haller index means were analyzed. A paired comparison of preoperative and postoperative means showed two distinct groups. An 86% canonical correlation was found between the anthropometric index and the Haller index. Conclusion: Patients with pectus excavatum can be quantitatively assessed in the preoperative and postoperative periods through the use of the anthropometric index, which allows objective, comparative evaluation of the results and is easily performed. J Bras Pneumol 2004; 30(6) 501-7. Key words: Funnel Chest. Anthropometry/methods. *Study carried out in the Departament of Cardiology and Pulmonology of the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Thoracic Surgery Sector. Correspondence to: Eduardo Baldassari Rebeis. Rua Alfredo Guedes, 1949, Cj 505 – CEP 13416-016 Piracicaba, SP. Phone: 55-19-3422 4078 E-mail: [email protected] Submitted: 29 January 2004. Accepted, after review: 13 May 2004. 501 Rebeis, Eduardo Baldassari, et al. Anthropometric index for quantitative assessment of pectus excavatum INTRODUCTION preoperative and postoperative periods, has been Congenital chest malformations have been either subjective(15) (clinical inspection) or described and discussed in the literature since the objective(3,16-20) (clinical or radiological evaluation), 15th century(1). Pectus excavatum (PEX) is the most depending on surgeon experience. There are very prevalent congenital malformation of the anterior few studies in the literature on clinical chest wall, affecting 1 out of 400 newborn measurements used to classify or quantify PEX. children, who present aesthetic alterations with Radiological measurements have also been possible psychological and social consequences adopted in order to quantify PEX. Derveaux et al.(20), that interfere with the quality of life of these using lateral chest X-rays and evaluating the individuals(2). Few studies have clinically and relationship between anteroposterior indices at the objectively classified the extent of these anatomical level of the angle of Louis and those seen at the distortions in order to quantify the depression, xiphoid process level, classified patients with chest make comparisons among groups and evaluate abnormalities in comparison to normal individuals. postoperative results(3). In addition, computed tomography (CT) scans were The etiology of PEX has not been well used to quantify PEX. In 1987, Haller et al.(16) established yet. Some authors have reported that created the Haller index, which is the ratio between there is an abnormal growth of chondrocostal the transverse diameter and the anteroposterior cartilage, which dislocates the sternum toward the diameter, obtained from the axial tomography slice spine(4). In 1939, Ochsner et al. wrote the first at a mediastinal window setting at the level of monograph on the subject, hypothesizing that the maximum depression. When this ratio is greater depression of the sternum was due to the abnormal than 3.25, PEX is considered moderate or severe, growth of cartilage(5). and surgery is indicated in order to correct the The PEX condition can be classified as deformity. Nakahara et al.(21) also conducted a study symmetric or asymmetric. When it is asymmetric, based on CT scans, numerically quantifying the the major depression is almost always to the right. depression, asymmetry, and flattening of the The sternal notch is frequently normal or a little deformity. distorted, as are the first and second costal arches. The main objective of our study was to devise In more severe cases, there is considerable simple, easily performed clinical anthropometric dislocation of the heart upwards and to the left, tools for the appropriate quantification of PEX in with significant reduction in chest volume. Despite outpatients. In view of this, we want not only to the deformity, most heart and pulmonary function compare various groups of patients during tests are normal, or there is only a discrete preoperative and postoperative periods but also reduction in the total lung capacity and inspiratory to evaluate these findings more concretely and vital capacity(6). In view of this, various studies have objectively so that multicenter studies can be dealt with functional results in preoperative and carried out. postoperative PEX, and there is consensus that there are no significant measurable changes in METHODS cardiorespiratory function, although there is Between December of 2001 and December of subjective improvement, especially an increase in 2002, we studied 10 patients with PEX and 10 exercise tolerance(7). patients with no morphological thoracic alterations Most authors have considered surgery the (controls). The patients with PEX ranged in age treatment of choice for severe PEX(8-10). The ideal from 10 to 31 years (mean, 17.4 years), 5 were age for surgical correction is still debatable, and male, 9 were White, and 1 was Asian. Patients unfit recommendations range from 4 to 12 years(11-14). for surgery or with diseases that would increase Surgical criteria for candidacy are based on morbidity of the surgical procedure were excluded. aesthetic and psychological aspects of patients. The age of the patients in the control group ranged Therefore, cosmetic results should be not only from 16 to 35 years (mean, 25.8 years), 6 were valued but also considered the best indication of male, and all were White. Patients with diseases therapeutic success. that might interfere with the morphology of the The evaluation of patients, both during thoracic cage were also excluded. 502 Jornal Brasileiro de Pneumologia 30(6) - Nov/Dez de 2004 The entire sample was clinically assessed at the sternal notch level at the point of maximum deformity or, in the case of control group patients, at the level of the distal third of the sternum. Patients with PEX underwent surgery and were reassessed between the 60th and the 80th postoperative day. All determinations were performed with patients in recumbent position on a flat table parallel to the floor while patients deeply inhaled. The materials used for clinical assessment were a T-square, a ruler with a built-in level, a bolt with a limiting nut, and a standard ruler (Figure 1). Measure A was the distance between the coronal plane tangential to the thoracic spine and the coronal plane tangential to the highest point Figure 1 – Material used for clinical measurements of the costal margin, at the level of maximum deformity or at the lower third of the sternum. Measure A’ was similar, but was assessed at the the muscular plane is drained with continuous sternal notch level (Figures 2 and 4). Measure B suction. In order to control pain, 8 patients (80%) was the distance between the plane tangential to received analgesics through a peridural catheter the highest point of the costal margin and the upon request. The other 2 patients (20%) received plane encompassing the lowest point of the nonsteroidal anti-inflammatory drugs and opioid sternum (both planes were parallel to each other) analgesics. at the level of maximum deformity or at the lower In addition, all patients were evaluated third of the sternum. Measure B’ was similar, but tomographically in the slices at mediastinal window was assessed at the sternal notch level (Figures 3 settings at the level of the sternal notch and at the and 4). We defined the anthropometric index for point of maximum deformity or at the distal third PEX as measure B divided by measure A (Figure of the sternum, in accordance with the technique 4). described by Haller(16). The Haller index is defined All patients underwent surgery in accordance as the internal latero-lateral distance divided by the with the Robicsek(22) technique, modified by the internal anteroposterior distance at the point of Thoracic Surgery Group of the Hospital das Clínicas maximum deformity (A/C). This index was also of the Faculdade de Medicina da Universidade de calculated at the sternal notch level (A’/C’) in keeping

Load more