胸腔镜微创Nuss手术治疗小儿漏斗胸

目的:探讨胸腔镜辅助下漏斗胸矫形术(Nuss手术)的优越性。方法:在胸腔镜辅助下实施漏斗胸矫形术2例。结果:手术过程顺利,手术时间分别为35、30m in,术中出血1~2m l,均恢复顺利,分别于术后第4天和第5天出院,分别随诊1年和10个月无任何并发症出现。结论:Nuss手术具有切口小而隐蔽、手术时间短、出血少、活动早、手术创伤小、无手术瘢痕、矫形效果好等优点,手术方法安全可行,值得推广。     

MSCT低剂量扫描在小儿漏斗胸Nuss术的应用价值

目的探讨MSCT低剂量扫描在小儿漏斗胸Nuss术的应用价值。方法搜集漏斗胸并Nuss手术患者73例,其中30例术前先行胸部CT常规剂量扫描后,对漏斗胸测量层面加作低剂量扫描,比较两种扫描方式图像质量及有效剂量差异。其余43例及Nuss术后56例只行胸部CT低剂量扫描。分析Haller指数与心脏旋转角的相关性,比较Nuss手术治疗效果。结果 MSCT低剂量扫描接受的辐射剂量较常规剂量扫描明显减低,ED降低至33%,差异有统计学意义(P<0.01)。术前Haller指数与心脏旋转角呈正相关(r=0.824,P<0.01)。术后Haller指数与术前比较有统计学差异(P<0.01)。结论小儿漏斗胸MSCT低剂量扫描在保障图像质量的前提下,明显减低辐射剂量同时,能有效评价漏斗胸胸廓的畸形及心脏受压旋转程度,为手术方式的制定及术后疗效的观察提供重要参考指标。     

Nuss手术矫治复杂漏斗胸

目的 总结Nuss手术治疗复杂漏斗胸的临床经验.方法 2006年9月至2009年10月,采用Nuss于术治疗169例漏斗胸病儿,其中复杂漏斗胸45例,术前常规行胸部CT和心脏B超等检查.有合并症者同时行合并症矫治,极重度和严重不对称漏斗胸分别采用剑突下小切口辅助、个性化钢板、多钢板放置、斜行放置钢板等方法完成矫治.结果 45例均顺利完成手术,平均手术时间54 min,术后4例出现少量气胸或皮下气肿,术后平均住院7天.矫形效果为优秀30例,良好13例,中等2例.所有病儿均获得随访,效果满意.结论 对复杂漏斗胸术前必须完善诊断,并分别和综合采用多种改良的Nuss手术方法,可以达到较好的矫治效果.     

改良Nuss手术纠治小儿漏斗胸

目的 总结胸腔镜辅助下改良Nuss手术纠治小儿漏斗胸的初步经验.方法 2004年6月至2006年7月,采用胸腔镜辅助下改良Nuss手术纠治53例漏斗胸患者,年龄2.4～16.0岁,平均年龄8.1岁.36例畸形为对称型,17例为非对称型.结果 53例患者均顺利完成手术,术中平均失血量少于10 ml.2例术中发生心包穿孔,6例术后出现少量气胸,3例术后出现胸腔积液,均经相应的处理治愈.术后平均住院5.5 d,所有患者均未输血,胸廓畸形矫正满意.测量胸骨凹陷48例得到完全纠正,5例残余凹陷小于术前程度的20%.矫形效果46例为优良,7例为良好.全部患者均获得随访,随访时间1～25个月,均无不适,活动量与正常的儿童相同,钢板无移位,无伤害事件发生.其中1例术后24个月拆除钢板,矫形效果仍保持优良.结论 改良Nuss手术简单、易行,对患者创伤小,近期矫形效果满意.胸腔镜监测可提高手术的安全性.胸腔镜辅助下Nuss手术是一种值得尝试和推广的手术方法.     

微创Nuss手术治疗漏斗胸复发患者12例

目的 总结微创Nuss手术对漏斗胸修复失败的治疗效果,以提高治疗水平. 方法 运用微创Nuss手术对12例初次接受Ravitch手术复发性漏斗胸患者进行再次修复,患者均为男性,年龄8～17岁,平均年龄15.6岁;Haller指数均大于3.25;主要症状包括呼吸急促、胸痛、哮喘或哮喘样症状和反复上呼吸道感染.体格检查和CT扫描提示:心脏受压、心脏移位及其他心脏异常,术前肺功能检查多数患者低于正常值的80%.常规使用矫形板及固定片进行矫形;并对术前症状、术中资料、术后结果进行分析. 结果 平均手术时间100 min,较初次手术时间稍长.发生并发症为血胸2例、大量胸腔积液3例、切口疼痛超过1周1例,均经保守治疗治愈,无死亡和心脏穿孔患者.术后随访12例,随访时间6～20个月;随访结果12例患者术前症状均消失,7例患者运动耐力增加;体格检查示:心脏受压和心脏移位缓解,患者均对手术结果表示满意或非常满意.有8例术后用力呼气量(FEF)25%～75%较术前得到改善(P<0.05). 结论 对初次漏斗胸修复失败或复发患者应用Nuss手术矫正后可取得理想的效果.     

Nuss手术矫治漏斗胸412例

目的 探讨非胸腔镜辅助下Nuss手术治疗漏斗胸的手术方法并总结治疗经验.方法 2005年10月到2011年6月非胸腔镜辅助下Nuss手术治疗漏斗胸412例,其中男329例,女83例.年龄2岁8个月～28岁5个月,平均7岁8个月.其中102例行内固定取出手术.结果 患儿均顺利完成手术,无术中严重并发症发生.手术平均40 min,出血(10±2) ml.结论 非胸腔镜辅助Nuss手术安全可行,并且不用进入胸腔操作,手术创伤更小,耗时更短,微创效果更好.     

胸腔镜下漏斗胸微创矫治术(Nuss手术)112例

目的:总结胸腔镜下漏斗胸微创矫治术(Nuss手术)治疗小儿漏斗胸(pectus excavatum,PE)的临床经验.方法:2005年7月～2012年9月采用胸腔下Nuss手术治疗漏斗胸112例,年龄3～21岁,平均13.6岁.其中对称性PE71例,不对称性PE41例.结果:112例均顺利完成手术,没有严重的并发症和死亡率.手术时间40～85分钟,平均51.5分钟,术中出血均少于20ml.住院时间4～8天,平均5.3天.早期并发症包括3例气胸,1例经穿刺抽气治愈,2例没有特殊处理而自行吸引.晚期并发症包括2例支撑架移位,1例重新手术矫正,另一例没有特殊处理.已有83例术后满2年患者取出支撑板,术后评价:优71例(85.5％),良10例(12.0％),一般2例(2.4％).结论:胸腔镜下Nuss手术治疗漏斗胸手术时间短,出血少,创伤小,并发症少,效果满意,是一种操作简便、安全、可靠的治疗方法,值的大力推广.     

双支架Nuss手术治疗青少年漏斗胸

目的 探讨使用双支架治疗青少年大范围漏斗胸微创Nuss手术的适应证、可行性和手术方法及效果.方法 31例中男24例,女7例;年龄14～18岁,平均(15.32±3.12)岁.根据Hallar指数均评价为中到重度,凹陷范围为4个肋间以上.选择胸腔镜辅助Nuss手术两点或者多点双支架支撑固定法手术.结果 均采用双支架在胸腔镜辅助下顺利完成Nuss手术.术后住院5～10天,平均(7.48±1.95)天;随访4个月到5年.术中发生出血2例,支架滑动移位和间断疼痛2个月各1例,均治愈.结论 胸腔镜辅助双支架矫正大面积、不对称漏斗胸的Nuss手术对青少年是一种安全、有效的方法.

Abstract：

Objective To investigate the indication, feasibility and technique of minimally invasive nuss procedure with thoracoscope by using double braces in the treatment of wide-scope pectus excavatum repairing in adolescence. Methods 31 patients including 24 boys and 7 girls, suffered from pectus excavtum were corrected by nuss procedure under thoracoscope.The average age was (15.32 ± 3.89)years (ranged, 14 years and 18 years). All cases were moderate to severe degree according to Hallar index with depression scope of 4 ribs or more. A couple of braces of two-point or multipoint fixation for thoracoscopic-assisted nuss procedure were used. Results The procedure was successfully completed under thoracoscopy in all patients. Double braces were utilized in 27 cases, double are bars were required in 4 cases, and multipoint fixations were in 6 patients. The postoperative hospital stay was 5-11 days [average, ( 7.48 ± 1.95 ) days]. The duration of following up was one month to three years. The perioperative complications included intraoperative hemorrhage in 2 patients, bar invertion with displacement in 1, and interrupted pain for two months in 1. All patients recovered after expectant treatment. Conclusion Nuss procedure with double braces for the correction of a large area of asymmetric pectus excavatum under thoracoscopy is safe and effective technique for adolescence.     

Nuss手术矫治复杂漏斗胸95例

目的 总结Nuss手术矫治复杂漏斗胸的经验和方法.方法 2006年8月至2011年7月施行漏斗胸Nuss手术443例,其中Haller指数＞6的极重度漏斗胸、严重不对称漏斗胸、有合并症的漏斗胸、复发性漏斗胸以及需放置多根钢板方能矫形满意者纳入复杂漏斗胸范畴,共95例,依漏斗胸复杂性的不同,分别和综合采用多种改良的Nuss手术技术:多钢板、斜行钢板、双弧形钢板等个性化技术;改进钢丝固定方式;合用截骨术;辅助小切口;不同侧置入胸腔镜;合并症的分期或同期手术等.结果 95例均顺利完成手术,手术(90.13 ±39.12) min,失血量(45.41±19.23) ml,无严重术中并发症,术后并发症13.6％.术后平均住院(7.21±2.87)天,效果良好,优良率92.6％.结论 对复杂的漏斗胸采用改良的Nuss手术,综合运用多种技术能取得较满意的矫形效果.     

非胸腔镜辅助Nuss手术治疗漏斗胸123例

目的总结Nuss手术治疗漏斗胸及减少术中、术后并发症发生的临床经验。方法回顾性分析2010年6月至2013年3月四川大学华西医院123例漏斗胸行Nuss手术治疗的临床资料,男101例,女22例;年龄3～32（15．0±5．1）岁;身高80～183（155．5±25．0）cm;体重15～71（44．4±13．3）kg。其中2例为Ravitch术后复发患者,其余患者均为初次手术。术前胸部CT示：Hailer指数为4．1±1．4。结果所有患者均顺利完成手术,手术时间35～155（74.3±25．4）min,术后住院时间3～16（4．2±1．6）d。其中26例患者需植入2根矫形板,其余患者均只需植入1根矫形板。CT示：术后Hailer指数为2．6±0．6,与术前比较差异有统计学意义（P〈0．05）。术后共发生并发症15例,发生率12．2％。其中气胸4例次,切口感染5例次,1例患者考虑为机体对矫形板材质过敏,伤口长期渗血、渗液,最终患者选择提前取出矫形板;2例患者有轻度脊柱侧弯,7例患者术后1～3个月内发生矫形板移位,需再次手术,重新放置矫形板。结论Nuss手术安全、可靠,具有矫形效果佳、损伤小、恢复快等优点。     

胸腔镜下Nuss手术治疗小儿漏斗胸38例报告

目的探讨胸腔镜下Nuss手术治疗小儿漏斗胸的疗效和安全性。方法胸腔镜监视下用穿通器在胸骨凹陷最低点水平，两腋中线之间，于胸膜外经胸骨后穿通一遂道，放置支撑板将凹陷胸骨抬起，支撑板两端安装固定器。5例使用进口器械，33例使用国产器械。结果38例均在胸腔镜辅助下顺利完成手术，手术时间40～80min，平均50min。术中出血量5～30ml，平均16ml。36例放置1根钢板支撑，2例放置2根钢板支撑。术后气胸4例，皮下气肿16例，右侧固定器滑脱1例，钢板轻度翻转1例。术后住院7～21d，平均8d。38例随访3～22个月，平均11个月，优36例，良2例，优良率100％。结论胸腔镜辅助下Nuss手术治疗小儿漏斗胸方法安全可靠，疗效好，手术最佳时机3～12岁。     

不同镇痛方法在儿童漏斗胸Nuss手术术后的应用

背景漏斗胸（pectus excavatum,PE）为最常见的先天性胸廓畸形,Nuss手术为目前常用的手术方式,虽属微创手术,但术后疼痛剧烈,严重影响患儿术后恢复及生活质量。良好的镇痛能促进康复并提高患儿及家属满意度,故Nuss手术术后镇痛具有重要意义。目的对儿童PENuss手术术后镇痛的研究进展予以综述。内容常用的镇痛方式有静脉镇痛、胸段硬膜外镇痛、肋间神经阻滞、椎旁神经阻滞及多模式镇痛等,另外催眠疗法及术后焦虑处理对Nuss术后疼痛也有一定缓解作用。趋向上诉镇痛方法各有优缺点,如何根据患者及医院情况为Nuss手术患儿制定个性化的术后镇痛方案仍待进一步研究。     

Anesthetic management for the minimally invasive Nuss procedure in 21 patients with pectus excavatum

The aim of this study was to assess the anesthetic management and postoperative analgesic effect of continuous epidural infusion for the minimally invasive Nuss procedure. A total of 21 operated cases were analyzed retrospectively. Thoracoscopy was used in all cases. General anesthesia with endotracheal intubation was induced and maintained with oxygen, air, sevoflurane, and fentanyl in all cases. Thoracic epidural anesthesia was performed after induction at the level between Th4 and 12. When the bar was placed via insertion under the sternum, six patients exhibited sinus tachycardia and one showed premature atrial contraction for 2–4 beats before recovering spontaneously within 1 min. Operations were uneventful. The mean operating time was 115 min and anesthetic time was 193 min. In X-ray findings, residual pneumothorax and pleural effusion were found in seven (33.3%) and eight (38.0%) patients, respectively. In all cases, these symptoms were resolved spontaneously within 5 days. Epidural fentanyl (0.3 μg·kg⁻¹·h⁻¹) in 0.125% bupivacaine (0.15 ml·kg⁻¹·h⁻¹) or 0.2% ropivacaine (0.15 ml·kg⁻¹·h⁻¹) were used for 3 days to relieve postoperative pain. Postoperatively, 12 (57.1%) patients required no additional analgesics, and 4 (19.0%) patients required a single dose of dicrofenac sodium or pentazocine. Although the Nuss procedure is minimally invasive, we should pay attention to the possibility of many intra- and postoperative complications. Continuous epidural infusion of fentanyl with local anesthetics provides effective postoperative pain relief and prevents complications such as bar displacement after the Nuss procedure.     

Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation

Purpose

In a few patients, cardiac perforation and aortic injury have occurred during the Nuss procedure for pectus excavatum. The article details a modification of this procedure that enables the prevention of fatal complications.

Methods

Our subjects were 22 males and 13 females with pectus excavatum who were aged 8.2 ± 3.7 years. Their Haller's computed tomography index was 5.2 ± 1.5. An introducer is inserted into the pleura between the sternum and thymus instead of the thoracic depression under right thoracoscopic guidance. After the introducer reaches the internal cranial position of the left nipple, the thoracoscope is shifted to the left thoracic cavity. The introducer is subsequently guided to the left highest intercostal space under left thoracoscopic guidance.

Results

A single bar was inserted in 34 patients; 2 bars were required in 1 patient. The operating time was 95 ± 27 minutes and blood loss was 11 ± 6 g. Cardiac perforation did not occur in any patient.

Conclusions

Our modified technique has certain advantages: (1) the introducer does not rub against the pericardium and heart; (2) the tip of the introducer can be observed at all times with a thoracoscope; (3) the anterior mediastinum between the left and right thoracic cavities is very narrow at the cranial level; (4) the introducer can be accurately directed to the left highest intercostal space; and (5) hemostasis and no injury of the bilateral thoracic organs can be confirmed.     

Efficacy of left thoracoscopy and blunt mediastinal dissection during the Nuss procedure for pectus excavatum

Background/Purpose

The minimally invasive Nuss procedure is emerging as the preferred technique for repair of pectus excavatum. Original methods of pectus bar placement have been modified to improve safety and efficacy and avoid cardiothoracic complications. The currently reported modifications to facilitate retrosternal pectus bar placement include routine use of right thoracoscopy or a subxiphoid incision. The purpose of this article is to describe additional modifications of the Nuss procedure to improve safety and efficacy.

Methods

A retrospective analysis was performed on 51 patients who have had a thoracoscopic-assisted Nuss procedure at The Children's Hospital, Denver, Colo, between 1999 and 2002. Technical modifications included patient positioning, routine use of left thoracoscopy, and an Endo-kittner.

Results

Fifty-one patients have successfully undergone the Nuss procedure using the new modifications. Surgical time ranged from 45 to 120 minutes. There have been no intraoperative or postoperative bleeding complications. There have been 2 large pneumothoraces requiring needle thoracenteses in the operating room before extubation. No chest tubes were required postoperatively. Subjectively, all patients have been satisfied with their surgical correction. Average length of hospital stay was 4 to 6 days.

Conclusions

By using left chest thoracoscopy and Endo-kittner dissectors, the risk of cardiothoracic injury can be eliminated. Moreover, other methods to ensure safe substernal dissection are unnecessary.     

Health-related quality of life after Nuss procedure for pectus excavatum: a cross-sectional study

Open in a separate window OBJECTIVESPectus excavatum (PE) can cause both physical and psychosocial symptoms and affect patients’ health-related quality of life. Previous international studies have shown that the Nuss procedure increases both self-esteem and body image. The aim of the study was to evaluate the health-related quality of life in patients who have undergone the Nuss procedure for PE.METHODSThe study had a cross-sectional multicentre design. All patients (N = 420) who underwent the Nuss procedure for PE in 3 cardiothoracic departments in Sweden from 2000 to 2019 were invited to answer the RAND-36 and Nuss Questionnaire modified for adults. Genders were compared using the Mann–Whitney U-test. Patients were divided into groups based on age at time of surgery (<20, 20–30 or >30 years) and analysed by the Kruskal–Wallis H-test with post-hoc analyses.RESULTSA total of 236 patients returned the questionnaires; 82.2% were males. Men scored significantly better on the modified Nuss Questionnaire total (P = 0.01) and psychosocial (P = 0.02) subscales. Patients who had surgery at <20 years of age had significantly better scores on the same scales (P = 0.007 and 0.006, respectively) compared to patients aged 20–30 years at the time of surgery. However, no significant difference was seen in comparison with patients >30 years. Patients who had their bar removed had significantly better values on both scales.CONCLUSIONSMale gender, young age at surgery and bar removal seem to be associated with better health-related quality of life after the Nuss procedure for PE.     

Z字形钢针在漏斗胸Nuss手术中应用的实验研究

目的 观察Z字形钢针矫治大鼠漏斗胸的固定效果。方法按Nuss介绍的方法，利用Z字形克氏钢针对12只漏斗胸大鼠进行胸壁畸形矫正手术。结果接受Nuss手术的12只漏斗胸大鼠中，除1只因切口感染提前取出内固定外，另11只的内固定按期取出。其中9只矫形效果满意，2只明显改善，1只因提前取出内固定而畸形复发。矫治畸形总优良率和钢针固定稳固率均为91．7％（11／12）。结论在大鼠漏斗胸的Nuss手术中，利用Z字形钢针矫正胸壁畸形固定牢靠、矫形满意。