Nuss手术治疗合并其他畸形的漏斗胸

Nuss手术是目前矫治漏斗胸的主流术式,随着技术的进步和生活水平的提高,已获得广泛开展.漏斗胸合并其他胸部先天性疾病患者的外科治疗,一直是热点及难点.2006年1月至2007年11月我院在非胸腔镜辅助下行Nuss手术治疗漏斗胸患者114例,其中合并其他胸部疾病的13例,均取得了良好的效果.现将我们的经验报告如下.     

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.     

Nuss手术矫治复发性和胸部手术后继发性漏斗胸

目的 总结Nuss手术矫治复发性和胸部手术后继发性漏斗胸经验.方法 2004年6月至2011年9月18例复发性或胸部手术后继发性漏斗胸Nuss手术者中男12例,女6例;年龄3.1 ～14.8岁,平均(8.8±4.0)岁;体重11 ～55kg,平均(30.2±14.8)kg.10例为开放式漏斗胸矫治术后复发病例,8例为其他胸部手术后继发性漏斗胸.16例畸形为对称性,2例为非对称性.CT检查Haller指数5.4±3.4.手术均在胸腔镜辅助下完成.结果 全组均成功实施手术.所有患儿均置入1根钢板.17例置入右侧固定片,1例置入双侧固定片.16例矫形效果为优良,2例良好.矫形效果与初次Nuss手术相比,早期优良及良好率差异无统计学意义(P＞0.05).术后胸腔引流管放置1～4天.1例钢板移位于术后5个月行Nuss修正,重新固定移位之钢板.1例心脏穿孔出血,术中紧急行扩大胸骨正中切口,直视下修补心脏破口,术后复查超声心动图,心脏功能正常,无神经系统并发症.1例术后当天气胸合并皮下气肿,1例术后3天胸腔积液,此2例均行胸腔闭式引流后治愈.12例钢板拆除,钢板滞留24～45个月,拆除者10例保持优良,2例良好,无复发病例.结论 Nuss手术矫治复发性和胸部手术后继发性漏斗胸效果良好.     

漏斗胸合并先天性心脏病的外科治疗

我们自 1985年 1月～ 2 0 0 0年 12月 ,共收治先天性漏斗胸 13 0例 ,先天性心脏病 74 13例 ,其中漏斗胸合并先天性心脏病 5例 (占先天性心脏病 0 0 67% ,占漏斗胸 3 85 % )。并对 5例漏斗胸合并先天性心脏病的患者行同期手术治疗 ,现报告如下。1.临床资料与方法 :5例中男 2例 ,女 3例 ;平均年龄 8岁 ( 5～ 19岁 ) ;2例继发孔型房间隔缺损 ,2例室间隔缺损 ,1例法乐四联症 ;均同期进行了胸骨翻转术和体外循环下心内直视纠治术。术前漏斗胸经体检与胸部Ｘ线 ,先天性心脏病经超声心动图或右心导管检查明确诊断。患者全麻下 ,行胸部正中切口。…     

先天性肺囊性腺瘤样畸形的诊断和治疗

目的 总结小儿先天性肺囊性腺瘤样畸形的诊断及手术治疗，提高对该病的认识。方法 对24例术前均摄胸部X线平片、CT并经手术、病理证实的先天性肺囊性腺瘤样畸形病儿的临床资料进行回顾性总结。其中男13例，女11例，平均年龄4．75岁，主要症状是呼吸道感染及呼吸困难，病史ld至8年。结果 影像学术前确诊率79．17％。24例行开胸术，证实病变均为单侧，侵犯1个肺叶22例，其中左叶15例、右叶7例；侵犯2个以上肺叶者2例。14例与支气管无交通，l例合并胸主动脉的异常血供，l例合并巨大实性肿物。20例行肺叶切除、3例行肺段切除、l例因胸膜肺母细胞瘤行全肺切除。全组无术后并发症。按Stocker分型：I型13例，Ⅱ型9例，IⅡ型2例。结论 影像学检查是诊断先天性肺囊性腺瘤样畸形的主要方法。对有症状者，手术切除病变侵犯的肺组织是治疗该病安全、有效的方法。     

CT在漏斗胸诊断和微创Nuss手术中的作用

目的 探讨CT在漏斗胸术前诊断和微创Nuss手术中的应用.方法 2002年7月到2008年9月648例NUSS手术病例均行术前CT检查,分析病人胸廓的畸形程度、分型、与周围脏器的关系和发现合并症,对手术进行指导和评价.结果 648例均顺利完成手术,CT分度为中度73例(11.27%),重度575例(88.73%).对称型407例(62.81%),偏心型83例(12.81%),不均衡型158例(24.38%).术前发现其他合并症116例(17.90%),CT检查确诊55例,占发现合并症的47.41%;55例中28例同期进行了手术.结论 CT能有效评价胸廓的畸形程度、分型、指导手术的入路、减少并发症的发生,并能进一步发现其他先天畸形等合并症,还是漏斗胸微创Nuss手术的术前常规检查和重要评估手段.     

经胸骨正中切口直视Nuss手术治疗先天性心脏病合并漏斗胸的单中心经验

目的探究经胸骨正中切口实施直视Nuss手术治疗先天性心脏病(先心病)合并漏斗胸的优化策略。方法回顾上海交通大学医学院附属上海儿童医学中心2017年1月至2021年11月, 接受经胸骨正中切口直视Nuss手术的25例先心病合并漏斗胸患儿。同期纠正心脏解剖畸形和漏斗胸组(A组)9例, 身高(121.7±28.0)cm, 体质量(22.2±14.0)kg, 年龄(7.65±4.08)岁, Haller指数3.99±1.37;先心病术后再次行漏斗胸Nuss手术组(B组)16例, 身高(130.9±27.2)cm, 体质量(26.5±14.3)kg, 年龄(8.82±4.09)岁, Haller指数4.18±0.97。术前分别通过超声心动图和计算机断层扫描评估所有患儿的心脏解剖情况、心功能和漏斗胸严重程度。分别记录两组患儿性别、术前漏斗胸外观、合并先心病种类、有无分离胸骨后粘连情况以及漏斗胸手术与先心病手术间隔年限。分别记录两组患儿的手术时间、住院天数、手术效果、术中不良事件、术后并发症以及随访情况。结果 25例患儿均顺利完成手术, 无术中不良事件, A组1例术后伤口感染。A组手术(3.78±1...     

双肺移植同期Nuss手术治疗造血干细胞移植术后闭塞性细支气管炎综合征合并胸廓畸形长期生存1例

目的  探讨双肺移植同期Nuss手术治疗造血干细胞移植术后闭塞性细支气管炎综合征（BOS）合并漏斗胸的疗效。方法  2015年3月24日,1例造血干细胞移植术后BOS合并漏斗胸患者在南京医科大学附属无锡市人民医院胸外科暨肺移植中心接受体外膜肺氧合（ECMO）辅助下双肺移植术,同期行Nuss手术矫治漏斗胸,手术顺利,术后予抗炎、抗真菌预防治疗,予他克莫司+吗替麦考酚酯+肾上腺皮质激素三联免疫抑制方案治疗。结果  患者术后恢复顺利,于术后25 d出院,术后2年拆除胸部Nuss钢板,胸廓畸形得到纠正,术后接受长期随访,截止至投稿日,患者存活3年余,肺功能恢复良好,生活质量满意。结论  双肺移植同期Nuss手术是治疗终末期BOS合并胸廓畸形的有效办法。     

Nuss手术治疗小儿漏斗胸(附60例报告)

目的 介绍微创Nuss手术治疗小儿漏斗胸的手术方法、并发症和相关临床经验。方法56例胸腔镜辅助下行Nuss手术，4例合并肺部病变同时开胸行肺切除。其中男43例，女17例；年龄2岁10个月～15岁，平均6岁2个月。结果 60例均顺利完成手术，无术中并发症。手术时间30～60min；所有病儿均应用钢支撑架；术中平均出血量4.9ml；术后平均住院6.5d；随访9～23个月。术后早期并发气胸1例(1.7％)；3例出现晚期并发症(5％)，间断疼痛2个月、持续性疼痛后导致获得性脊柱侧弯、支撑架滑脱各1例。结论 微创矫正小儿漏斗胸的Nuss手术方法安全可行。广泛对称性漏斗胸，尤其扁平胸是Nuss手术的最佳适应证。病儿手术修复最佳时机为6～12岁，可扩展至3～15岁。技术方法的改进和远期效果的评价，还需进一步研究探讨。     

非胸腔镜辅助微创Nuss手术治疗先天性漏斗胸疗效评价

目的比较非胸腔镜与胸腔镜辅助微创Nuss手术治疗先天性漏斗胸的临床疗效。方法按照手术方式不同将我院收治的66例先天性漏斗胸患儿分为实验组35例和对照组31例,实验组患儿给予非胸腔镜辅助微创Nuss手术治疗,对照组患儿给予胸腔镜辅助微创Nuss手术治疗,比较两组患儿一般手术情况、围术期并发症以及近期疗效。结果两组患儿均顺利完成手术,实验组患儿手术时间显著短于对照组,差异有统计学意义（P〈0.05）;两组患儿术中出血量及术后住院时间比较,差异无统计学意义（P〉0.05）;两组患儿优良率和并发症发生率比较,差异无统计学意义（P〉0.05）。结论非胸腔镜辅助微创Nuss手术治疗先天性漏斗胸疗效与胸腔镜辅助微创Nuss手术相同,但非胸腔镜辅助微创Nuss手术简化了手术操作,缩短了手术时间,临床应用价值更高。     

Minimally invasive Nuss technique allows for repair of recurrent pectus excavatum following the Ravitch procedure: report of 12 cases

This work aimed to determine the efficacy of recurrent pectus excavatum repair using a minimally invasive Nuss procedure. We performed a secondary repair in 12 patients with recurrent pectus excavatum by using the minimally invasive Nuss procedure. Prior repairs had been performed using the Ravitch procedure in all cases. The values obtained in preoperative pulmonary function tests were less than 80% of the normal values. The median duration of surgery was slightly longer than that of the primary surgeries. The procedural complications included hemothorax (16.7%) and pleural effusion (25.0%). None of the patients developed a pneumothorax, pericarditis, pneumonia, wound infection, or immune rejection. There were no deaths or cardiac perforations. Exercise tolerance increased in 7 of the 12 cases. We achieved excellent results from surgical correction using the Nuss procedure in these 12 patients who showed recurrent pectus excavatum after failed repair surgery using the Ravitch procedure.     

The Nuss Procedure After Breast Augmentation for Female Pectus Excavatum

Pectus excavatum, the most common congenital chest wall malformation, has a higher incidence among men. Since 1987, when Donald Nuss performed his technique for the first time, the minimally invasive approach has become the most widely used technique for treating pectus excavatum. Few reported studies have focused on the repair of female pectus excavatum. Women with pectus excavatum often present with breast asymmetry that may require breast augmentation, either before or after pectus excavatum repair. To the authors’ knowledge, no reports on the Nuss procedure after breast implant surgery have been published. This report describes the case of a 26-year-old woman who underwent minimally invasive repair after breast implant surgery. The authors believe that for women with severe pectus excavatum, the Nuss procedure should be the first choice for surgical correction. Moreover, for breast implant patients, this technique is absolutely feasible without major complications.     

经腋中线直切口行Nuss手术纠治小儿漏斗胸

目的总结经腋中线直切口行Nuss手术纠治小儿漏斗胸的手术技巧和疗效。方法2010年6月～2012年1月,对18例先天性漏斗胸采用两侧腋中线直切口进行胸腔镜辅助下Nuss手术,手术年龄5岁2个月～11岁8个月,平均7岁3个月。根据Park分型,对称性11例,不对称性7例。Haller指数3．3—10．8,4．68±1．73。结果18例均顺利完成手术,手术时间30～55min,（42．2±6．5）min。术中失血量〈10ml。1例发生少量气胸,保守治疗气胸消失。伤口均愈合良好。住院时间（5．1±1．0）d。术后3个月门诊随访,手术效果：优14例,良4例。18例随访时间3～18个月,（10．0±4．5）月,其中5例〉12个月,支架钢板无明显移位或滑脱,胸廓外形发育良好。胸廓矫正满意,正面和侧面手臂下垂时均无法发现腋中线切口。结论经腋中线直切口行Nuss手术纠治小儿漏斗胸是可行的,特别对于女性患者,可以避免影响乳腺的发育和外观。     

胸膜外Nuss手术与Nuss手术对比研究

目的 前瞻性对比胸膜外Nuss手术和Nuss手术的安全性和可行性.方法 2008年7月至2009年6月252例行Nuss手术者,排除漏斗胸复发、有合并症同期手术、大于13岁、广泛凹陷使用双支撑架和极重度和严重非对称性者,余131例随机分两组,62例胸膜外Nuss手术组和69例Nuss手术组.比较两种术式同手术期情况、并发症和手术效果,并观察胸膜外组钢板是否确在胸膜外.结果 131例均顺利完成手术,在两组年龄、Haller指数差异无统计学意义的前提下,手术优良率、手术时间、术中出血量和出院时间差异亦均无统计学意义.随访14～26个月,无复发及远期并发症,两组并发症各3.例,差异无统计学意义.胸膜外组32例破入胸腔.结论 胸膜外Nuss手术是安全可行的,但与Nuss手术组在手术时间、术中出血、出院时间和手术效果上无任何优势,且不容易观察到对侧胸腔情况,手术方法不容易掌握和推广.

Abstract：

Objective To compare the safety and feasibility of thoracoscopic extrapleural Nuss procedure with traditional intrapleural Nuss procedure. Methods Total 252 patients with pectus excavatum received Nuss surgery from July 2008 to June 2009 in Beijing children' s hospital. Patients had following condition were excluded; (1) recurrent pectus excavatum; (2) complicated with other diseases, and need simultaneous surgery; (3) older than 13-year-old; (4) extensive depression, and need two Nuss bar; or (5) extreme severe or severe unsymmetric. 131 cases were selected in our study and they were randomly divided into two groups, thoracoscopic extrapleural Nuss procedure ( n = 62 ) and traditional intrapleural Nuss procedure ( n =69). Perioperative information, postoperative complications, effectiveness and the location of the Nuss bar were compared between two groups. Results All the 131 patients had completed the procedure successfully. There were no significant differences in age, Haller index; surgical effects, operation time, blood loss, and hospital stay, between two groups. Postoperative complications between the two groups are not significant. 131 patients were followed up from 14 to 26 months, and no recurrence and long-term complications occurred. About more than half cases of extrapleural Nuss procedure group were break the pleural into thoracic cavity. Conclusion Both extrapleural and intrapleural Nuss procedure are safe and effective for pectus excavatum, but extrapleural Nuss procedure have no advantage to the intrapleural Nuss procedure, also it' s hard to observe the other side of thoracic cavity during the surgery, and not easy to grasp and to promote.     

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.     

Anterior chest wall deformities and congenital heart disease

Pectus excavatum and pectus carinatum usually exist as isolated abnormalities. Only 19 cases of associated congenital heart defects have been reported. Significant complications related to uncorrected pectus excavatum have been described either during or after cardiac operations. Therefore we reviewed our experience with these coexisting lesions to assess the risk of surgical repair of chest wall deformities before and after correction of congenital cardiac anomalies. Among 20,860 infants and children with congenital heart disease seen at our institution, 36 (0.17%) had associated anterior thoracic deformities, 22 of whom underwent surgical correction of pectus excavatum or pectus carinatum. Ten of these 22 patients had pectus repair after a cardiac operation. Pleural or pericardial entry was avoided in all and none required a blood transfusion. Ten other patients had pectus repair either before cardiac repair (five patients) or without a subsequent cardiac operation. Another patient had a cardiac operation performed through a median sternotomy both before and after pectus repair, and the remaining patient, early in the series, had simultaneous banding of the main pulmonary artery and repair of pectus excavatum complicated by chest wall instability and a lethal intrathoracic hemorrhage. The experience indicates that congenital chest wall deformities can be safely and effectively repaired after early correction of congenital heart defects through a median sternotomy, although repair of the chest wall deformity after cardiac surgery also gives good results. However, in children who require an extracardiac conduit for repair of their congenital heart defect, we recommend initial repair of the pectus excavatum followed at 6 weeks or later by repair of the cardiac lesion to eliminate possible extrinsic compression of the conduit by the depressed sternum. We avoid simultaneous cardiac and pectus excavatum repair because of potential associated major complications.     

漏斗胸Nuss术后钢板取出手术方法的改良

目的探讨漏斗胸Nuss术后钢板取出手术的改进方法。方法2008年1月～2011年2月64例漏斗胸Nuss术后钢板取出,27例为双侧切口,其中双侧固定片18例、单侧固定片9例,包括2例肋骨骨痂包绕成骨、2例严重漏斗胸;37例为单侧切口。采用单腔气管插管全麻,平卧位,选固定片侧原手术侧切口,将固定片外露出皮肤后去除,再使用骨科旋转器将钢板向外稍扳直后,向下沿着钢板弧度将钢板拉出。结果手术时间10-75min,平均21min;术中出血量5—450ml,平均为15ml。2例（3．1％）术中出血量〉400ml,为钢板固定片骨痂形成,术中损伤肋间血管导致出血;1例（1．6％）钢丝遗留再次手术去除;4例（6．2％）术后少量气胸,2例（3．1％）术后术口感染,保守治疗后痊愈。术后住院时间1—13d,平均2．5d。术后1年取出钢板2例（3．1％）,术后2年3例（4．7％）,术后3年59例（92．2％）。2年内拆除钢板原因为患者对钢板过敏致钢板外露（4例）和钢板严重移位（1例）。64例随访4～36个月,平均16．8月,所有患者均保持同术前相近的良好漏斗胸畸形矫正效果。结论漏斗胸Nuss手术患者钢板多在3年后去除,通过改良Nuss术后钢板取出手术方法,采用固定片侧原手术侧切口,将固定片外露出皮肤后先去除,然后将钢板向外稍扳直后沿钢板弧度不翻转钢板向下将钢板顺原位取出,可以减少和预防并发症发生。