Nuss operation for pectus excavatum: a single-institution experience

Background  

The Nuss procedure for repair of pectus excavatum (PE) has been accepted worldwide because of minimal invasiveness and excellent cosmetic results. We summarized our experience with the treatment of 115 patients aged 2.7–18 years.     

改良Nuss手术纠治小儿不对称型漏斗胸

目的总结胸腔镜辅助下改良Nuss手术纠治不对称型小儿漏斗胸的初步经验。方法2004年6月至2006年7月,我院共施行漏斗胸Nuss手术纠治53例,其中17例为不对称型,男13例,女4例。最小年龄2岁5个月,最大14岁,平均8.9岁。手术在胸腔镜辅助下完成。根据患儿畸形情况,设计个性化钢板形状,并对Nuss手术进行改良。结果17例患儿均顺利完成手术,术中平均失血少于15ml。1例患儿术后胸片显示少量气胸,1例患儿术后胸腔积血,1例患儿术后胸腔积液,无其他并发症。术后平均住院6d。13例获得对称性纠正效果,4例术后单侧稍扁平,畸形矫正满意。结论对不对称型漏斗胸采用个性化钢板弯制技术进行Nuss手术,能取得较好的矫形效果。     

微创新术式矫治47例漏斗胸的经验

目的报告并总结一种治疗漏斗胸的微创新术式的效果。方法2002年6月～2005年4月，47例2～18岁的漏斗胸患儿在四川大学华西医院小儿外科采用胸壁小切口，不作胸壁的广泛游离及不作多对肋软骨切除，经最凹陷处置人一金属支杠于胸骨下端深面的方法手术矫正漏斗胸。结果47例患儿在手术完成时即获满意的矫正效果，手术安全无并发症。42例随访时间3～35个月，其中38例在随访期内获得满意的胸廓外观，患儿运动耐受量及心理状况也有明显改善。另外4例患儿的畸形，也较术前改善。结论采用微创的新术式治疗漏斗胸患儿效果满意，安全可靠，瘢痕小，无严重并发症。     

Single incision Nuss procedure for pectus excavatum

Purpose  

To describe a unique single incision modification of the Nuss procedure and compare results to a historical cohort of standard Nuss patients.     

Complications associated with the minimally invasive repair of pectus excavatum

The minimally invasive pectus excavatum repair (Nuss repair) is performed by pediatric general surgeons and pediatric and adult thoracic surgeons around the world. Complications related to pediatric surgical procedures are always a major concern for surgeons and their patients, and as with all surgery, especially pectus surgery, complications can be life-threatening. The purpose of this article is to discuss early and late complications of pectus excavatum surgery and potential preventive strategies to minimize them.     

Technical innovation in minimally invasive repair of pectus excavatum

The aim of study was to introduce technical innovation of MIRPE which reduces the risk of cardiac injury. Modification of MIRPE method with semiflexible thoracoscope and sternum elevating technique has been used. Volkmann bone hook has been inserted percutaneously to the sternum. The hook elevates the sternum forward and enlarges the retrosternal space for safer passage of thoracoscopically guided introducer. Using semiflexible thoracoscope allows better view from various angles via one site of insertion. During the period 2005–2012, the MIRPE was performed on 29 girls and 151 boys; the mean age at the time of surgery was 15.9 years (range 13–18.7 years). The mean Haller index was 4.7 (range 2.7–20.5). The most common complication was pneumothorax (3.3 %) and the incidence of bar displacement was 2 %. The most serious complication was cardiac perforation when inserting Lorenz introducer. This occurred in a 16-year-old girl; she required urgent sternotomy with right atrial repair and recovered well. External elevation of sternum with the hook was used since this case. Subsequent 113 patients underwent surgery without any serious complications. Technical innovation using semiflexible thoracoscope and hook elevation of the sternum reduces the risk of cardiac injury. The hook opens the anterior mediastinum space effectively and makes the following dissection relatively safe and straightforward.     

非胸腔镜辅助Nuss手术矫治大年龄患儿漏斗胸

目的 探讨非胸腔镜辅助Nuss手术治疗大年龄患儿漏斗胸的手术方法 和治疗经验.方法 24例漏斗胸在非胸腔镜辅助下行Nuss手术治疗,其中男19例,女5例.年龄12岁2个月～17岁11个月,平均13岁10个月.结果 24例患儿均顺利完成手术,无术中严重并发症.手术耗时平均45 min,平均出血10 ml.结论非胸腔镜辅助Nuss手术治疗大年龄患儿漏斗胸,术中注意掌握要点,未发生危险并发症.手术仍安全可行.对大年龄漏斗胸患儿行Nuss手术的远期效果有待进一步观察.     

Enhancing recovery after minimally invasive repair of pectus excavatum

Purpose

There are variations in the perioperative management of patients who undergo minimally invasive repair of pectus excavatum (MIRPE). The purpose is to analyze the change in resource utilization after implementation of a standardized practice plan and describe an enhanced recovery pathway.

Methods

A standardized practice plan was implemented in 2013. A retrospective review of patients who underwent MIRPE from 2012 to 2015 was performed to evaluate the trends in resource utilization. A pain management protocol was implemented and a retrospective review was performed of patients who underwent repair before (2010–2012) and after (2014–2015) implementation.

Results

There were 71 patients included in the review of resource utilization. After implementation, there was a decrease in intensive care unit length of stay (LOS), and laboratory and radiologic studies ordered. There were 64 patients included in the pain protocol analysis. After implementation, postoperative morphine equivalents (3.3 ± 1.4 vs 1.2 ± 0.5 mg/kg, p < 0.01), urinary retention requiring catheterization (33 vs 14%, p = 0.07), and LOS (4 ± 1 vs 2.8 ± 0.8 days, p < 0.01) decreased.

Conclusion

The implementation of an enhanced recovery pathway is a feasible and effective way to reduce resource utilization and improve outcomes in pediatric patients who undergo minimally invasive repair of pectus excavatum.

     

Nuss手术治疗小儿漏斗胸118例

目的 总结Nuss手术治疗小儿漏斗胸的临床经验.方法 2006年9月～2009年4月,采用Nuss手术治疗118例漏斗胸患儿,其中男89例,女29例;年龄3～16岁,平均(6.4±3.5)岁.3例合并肺部病变患儿经单侧胸部切口完成肺部手术后,直视下安放Nuss钢板,6例复发病例采用胸腔镜辅助完成,其余病例在非胸腔镜下完成.结果 118例患儿均顺利完成手术,术中无死亡、大出血及胸腔脏器损伤等严重并发症发生.术后切口均Ⅰ期愈合.除3例合并肺部病变和1例行部分肋骨截骨患儿外,术中平均失血量<10 ml.术后14例出现少量气胸及皮下气肿,经穿刺抽气后消失,1例严重气胸经安置胸腔闭式引流后好转.所有患儿均获得随访,术后1个月及3个月复查均无钢板旋转移位,无固定片滑脱,无胸腔积液,无切口感染.矫形效果98例"优秀",20例"良好".结论 Nuss手术通过植入特制钢板使胸廓重新塑形,操作简单、微创、损伤小并具有良好的早、中期效果但Nuss手术对漏斗胸患儿肺功能的影响、最佳手术年龄以及远期效果的评价,还需要进一步探讨.     

微创手术矫治漏斗胸125例

目的探讨不同术式的微创手术矫治漏斗胸的特点及疗效。方法2003年3月至2008年2月,采用微创手术方法治疗漏斗胸125例。其中电视胸腔镜辅助微创手术52例;小切口直视微创手术28例;小切口不损伤胸肋骨微创手术15例;Nuss手术30例。除Nuss手术外,全部病人均选择钢板、克氏针倒T形内固定。结果手术后均恢复顺利,1例内固定钢板滑脱,术后3d重新手术固定。1例Nuss手术病人发生中量血胸。其余无重要并发症。术后胸片、CT复查胸骨位置全部恢复正常。随访2个月至2年,4例有胸壁局限性凹陷,其余病人效果满意。结论本文报告的微创手术方法创伤小,疗效好。手术年龄以3—5岁为宜。如胸骨凹陷较重,临床症状多,主张在2～3岁手术,并可选择不损伤胸骨和肋骨的微创术式。     

食管超声监测下非胸腔镜辅助Nuss手术85例分析

目的 探讨食管超声监测下非胸腔镜辅助Nuss手术的手术方法和治疗经验.方法 2011年8月至2014年8月本院对适合的漏斗胸病例采用食管超声监测下非胸腔镜辅助Nuss手术矫治漏斗胸,共85例患儿,其中男61例,女24例.年龄7岁8个月至17岁5个月,平均13岁2个月.胸廓指数(Haller index)在3.6～14.2之间,平均4.1.79例为初次漏斗胸手术,6例为复发漏斗胸,64例患儿置入1根钢板,21例置入2根钢板.结果 85例患儿均顺利完成手术,无术中严重并发症发生.手术时间28～70 min,平均40 min;出血量10～40ml,平均15ml.全部患儿术后未出现伤口感染,恢复顺利,术后5～7 d出院,平均6d.本组22例患儿术后钢板安置满3年已手术移除钢板.85例均获随访,随访时间14～38个月,平均23个月.患儿疼痛消失,活动量增加,无不适表现,患儿和家属满意矫形效果.结论 使用食管超声监测,术中能够比较清楚的反映术中心脏大血管及心包的状态,可以有效的发现并避免术中严重的并发症,食管超声在漏斗胸手术中为一种有效的监测手段.     

Nuss procedure in the adult population for correction of pectus excavatum

Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.     

Late-onset vital complication after the Nuss procedure for pectus excavatum

The Nuss procedure is the most popular technique for correction of pectus excavatum recently. Life-threatening complications associated with the procedure are very rare. We report a 13-year-old boy who developed late-onset bilateral hemothorax with hypovolemic shock 5 months after the Nuss procedure. In literature review, this is the first case of the late-onset life-threatening bilateral hemothorax with hypovolemic shock ever reported.     

Results of Nuss procedures for the correction of pectus excavatum.

INTRODUCTION: The principle of the Nuss procedure is remodulation of the chest using a steel bar inserted by means of two small skin incisions along the axillary lines. PURPOSE OF THE STUDY: The assessment of the outcome after treatment. MATERIAL AND METHODS: Between July 1998 and March 2003 66 children were operated on by Nuss technique to correct pectus excavatum in our department. Age ranged from 1 to 19 years (mean 11.8 years). The evaluation prior to surgery included chest X-ray and CT, pulmonology consultation with pulmonary function tests and cardiology consultation. We used a modified technique in which we inserted the supporting bar directly from the right side, with no thoracoscope, no sharp tools and no guiding tape. Intrapleural or epidural bupivacaine was used for postoperative pain control. RESULTS: Duration of the operation was between 20 and 60 min. Complications included wound infections in six children, haemothorax in three and pneumonia in one. In 56 children the early cosmetic results were very good. In 5 children the excavation of the lower part of the sternum has persisted, in 5 children the excavation of the sternum was corrected but asymmetric thickening in the parasternal region persisted. In all cases the results were satisfactory for both the children and their parents. In 24 children the supporting bar was removed two years after the first operation. Postoperative courses were uneventful and the cosmetic results were good. In one child we observed a recurrence of the deformity six months after bar removal. CONCLUSIONS: The early results of the new operation for pectus excavatum are good in most children. The minimal invasiveness of this method suggests that this procedure is indicated in cases where the defects are only cosmetic.     

Review and discussion of the complications of minimally invasive pectus excavatum repair.

PURPOSE: To review and discuss the complications of minimally invasive pectus excavatum repair. METHODS: 329 patients underwent minimally invasive pectus repair between January 1987 and August 2000, including 14 patients who recurred after previous Ravitch repairs, 10 failed Nuss repairs (eight done elsewhere) and two failed Leonard repairs. All patients received antibiotics and vigorous incentive spirometry to prevent atelectasis, pneumonia and bar infection. Epidural anesthesia was used for postoperative analgesia to keep patients comfortable and stable postoperatively and to prevent bar displacement. Thoracoscopy was used during bar insertion to minimize the risk of mediastinal injury and to select the best position for the bar. A new introducer was developed to elevate the sternum before bar insertion. A stabilizing bar was created to minimize bar displacement. The duration of sternal bracing has been increased from two years to three or four years in selected patients. COMPLICATIONS: There were no deaths, no cardiac perforations and no cases of thoracic chondrodystrophy. Pneumothorax with spontaneous resolution occurred in 52 % of the patients, with 1.2 % requiring simple aspiration and 1.5 % requiring chest tube drainage. This complication has essentially been eliminated by using a "water seal system". Pericarditis occurred in 2.4 % with good response to Indomethacin in six out of eight patients and two patients also required pericardial fluid aspiration. Pneumonia occurred in 0.9 %. Wound infection occurred in 2.6 % resulting in bar infection in three out of the seven patients. Long-term antibiotics were successful in curing the infection in one patient, whereas the other two required bar removal at 12 and 18 months, respectively. Bar displacement occurred in 8.8 % of patients. However, the introduction of stabilizers decreased the incidence from 15.7 % before the use of stabilizers to 5.4 % with stabilizers. Wiring the bar and stabilizer together has decreased the incidence even further. RESULTS: Long-term outcome after bar removal showed an excellent result in 71 %, good result in 21 % and recurrence in 7.8 %. CONCLUSION: The minimally invasive technique has a low complication rate with excellent long-term results.     

Radiologic considerations in patients undergoing the Nuss procedure for correction of pectus excavatum

The Nuss procedure has succeeded in minimizing incisions, blood loss, sternal fracturing, operating room time, recovery time, and length of hospital stay. Knowledge of the pre- and postoperative radiologic considerations is essential in providing appropriate imaging support to the surgeons performing this innovative, minimally invasive procedure. Received: 6 September 2000 Accepted: 11 January 2001     

NUSS手术治疗小儿漏斗胸的临床效果观察

目的探讨Nuss手术治疗小儿漏斗胸的临床效果。方法采用Nuss手术治疗小儿漏斗胸87例,男62例,女25例,平均年龄5.8岁(3～21岁),3～6岁43例,7～10岁28例,11～16岁9例,17～21岁7例。在胸腔镜监视下,先用弯钳在胸骨凹陷最低点切开胸膜,钝性分离胸膜外胸骨后隧道(避免在导入引导器时损伤心包);于胸骨凹陷最低点右侧肋间最高点穿入引导器至右侧胸腔,经分离的隧道紧贴胸骨至胸骨左侧,于左侧对应的最高点肋间穿出引导器;将矫形钢板凹面朝上导入,翻转180°顶起胸骨;两侧安装固定片,以2-0可吸收缝线将固定片与肋骨膜缝合;缝合肌肉和皮肤,不留胸腔引流管。手术后2年常规取出钢板。结果87例均顺利完成手术,无中转开放手术者,平均手术时间37.6min(24～120min),出血量2～10ml,手术后平均住院时间5.9d(2～9d)。无心包损伤发生。全部病例平均随访29.6个月(3～60个月),疗效满意78例(91.9%),获得改善5例(5.7%),不满意4例,差4例。年龄越小,满意度越高,3～6岁和7～10岁组满意度分别为97.6%、96.4%,而17～21岁组满意度为28.6%,二者差异有显著统计学意义(P<0.01);11～16岁组满意度为77.7%,比17～21岁明显增高(P<0.01),与3～6岁和7～10岁组比较无统计学意义(P>0.05)。结论Nuss手术矫治小儿先天性漏斗胸安全有效,具有损伤小,恢复快,兼顾美容的优点,年龄越小,效果越好。