比较Nuss手术与改良Ravitch手术治疗小儿漏斗胸的疗效

目的比较Nuss手术与改良Ravitch手术治疗小儿漏斗胸的效果。方法随机将78例漏斗胸患儿分为2组,每组39例。A组施行Nuss手术,B组施行改良Ravitch手术。观察比较2组手术效果。结果 A组手术时间、术中出血量、恢复活动时间及住院时间均短于B组,差异均有统计学意义(P0.05)。2组并发症发生率、优良率比较,差异均无统计学意义(P0.05)。结论 Nuss手术治疗小儿漏斗胸与改良Ravitch手术效果相当,但Nuss手术创伤小、恢复快,应根据手术适应证加以选择。     

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.     

改良Ravitch手术治疗成人复发性漏斗胸

目的观察改良Ravitch手术治疗成人复发性漏斗胸的效果。方法回顾性分析2007年7月至2010年1月新华医院收治的8例成人复发性漏斗胸患者的临床资料,均为男性;年龄18~26岁,平均年龄21.5岁。所有患者均采用改良Ravitch手术治疗。对术前症状、术中资料、术后结果进行分析。结果手术均顺利完成,术中无并发症发生,无死亡。患者胸廓畸形得到纠正,左右对称。术后发生左侧气胸2例,其中1例有胸腔积液,经胸腔闭式引流后治愈。无切口感染、浮动胸壁和反常呼吸等并发症发生。8例患者随访1~20个月,5例胸痛消失,1例胸痛明显缓解。呼吸急促等症状明显好转;无胸廓凹陷和浮动胸骨发生,无畸形复发。复查肺功能6例患者最大呼气中段流速(FEF)均80%,但用力肺活量(FVC)、一秒率(FEV1%)略有改善。结论成人复发性漏斗胸患者采用改良Ravitch手术再次矫正后可获得较满意的效果。     

改良Nuss手术治疗小儿漏斗胸37例

目的探讨剑突下小切口非胸腔镜辅助改良Nuss手术治疗漏斗胸的效果。方法2007年7月～2012年4月,37例4～12岁的漏斗胸患儿采用剑突下1个纵行小切口、侧方2个切口完成Nuss手术。结果37例患儿均顺利完成手术,手术时间（49．3±14．5）min,术中出血量（6．1±2．3）ml,住院时间（4．7±1．2）d。术中无心脏穿孔和大血管损伤。术后2例右侧气胸,1例钢板末端两侧切口因感染裂开。37例随访10—51个月,术后6个月评定35例矫形效果为优,2例为良好,无复发二次手术,术后2年钢板取出。结论利用剑突下切口手指辅助改良Nuss手术,减少了心脏损伤;剑突下切口引导简单、安全,易于掌握。     

Nuss手术及其改良术式治疗漏斗胸的早期经验与探讨

目的 总结微创漏斗胸矫形术(Nuss手术)及其改良术式治疗漏斗胸的早期治疗经验.方法 39例对称性漏斗胸患者采用Nuss手术治疗,即在胸腔镜监视下将矫形钢板由一侧胸腔经胸骨后穿至对侧胸腔,翻转后固定.3例非对称性漏斗胸患儿采用改良Nuss手术.结果 42例患者均顺利完成手术,手术时间20～60 min,平均31.3 min,出血量10～50 ml.住院时间3～12 d,平均5.7 d.6例患者术后疼痛较明显,3例患者出现发热,对症治疗后改善.无气胸及皮下气肿、无切口感染.术后3～18个月随访,40例患者矫形效果满意.2例患者术后矫形板移位,1例再次手术.结论 Nuss手术治疗漏斗胸具有微创、美观、创伤小,安全可靠的优点,便于推广;非对称性漏斗胸患者采用改良Nuss手术治疗,近期效果满意,远期效果还需观察.     

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。     

改良Ravitch术矫治先天性漏斗胸

漏斗胸（peetus excavatum）是比较常见的先天性胸廓畸形，多需手术治疗。1998年10月至2005年2月，我们应用自行设计的改良Ravitch术矫治先天性漏斗胸，现报道如下。     

改良Ravitch术治疗小儿漏斗胸10例报告

改良Ｒａｖｉｔｃｈ术治疗小儿漏斗胸１０例报告航天工业部中心医院胸心外科（１０００３９）刘文海，杨泽泉，王建国，杨跃，詹学斌，孙跃民，游小明１９９２年１０月至１９９４年１月间我们采用了改良Ｒａｖｉｔｃｈ术式先后为１０例漏斗胸患儿施行了根治矫正术．取得理...     

两切口Nuss手术与传统Nuss手术的对比研究

目的探讨两切口Nuss手术治疗漏斗胸的安全性和可行性。方法回顾对比分析2005年10月～2007年10月103例传统三切口Nuss手术（Nuss组）,与105例改良两切口Nuss手术（Nuss改良组）的临床资料,比较2种术式围手术期情况、并发症和手术效果。结果208例均顺利完成手术,Nuss改良组手术优占94.3%与Nuss组88.3%无统计学差异（x^2=2.318,P=0.128）。Nuss改良组患者的手术时间（39.2±7.4）min、术后住院时间（6.3±0.7）d均显著短于Nuss组（45.4±9.2）min、（7.2±0.9）d（t=5.361,P=0.000;t=8.059,P=0.000）。Nuss改良组患者术中出血量中位数为2.8 mI,显著少于Nuss组3.0 ml（x^2=5.158,P=0.000）。2组发生并发症各5例（Nuss组：1例气胸、1例血胸、1例心包穿孔和2例膈肌及肝脏损伤;Nuss改良组：气胸4例、心包穿孔1例）,无统计学差异（x^2=0.001,P=0.975）。随访3～30个月,无复发及远期并发症。结论改良两切口Nuss手术不但减少了一个切口,其手术时间、术中出血量和术后住院时间明显优于传统三切口Nuss手术;而且更容易观察到对侧的情况,安全和可行。     

胸壁、胸膜：改良Nuss手术纠治小儿不对称型漏斗胸

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，设计个性化钢饭形状，并对Nuss手术进行改良。结果：17俐患儿均顺利完成手术，术中平均失血少于15mL。1例患JL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。     

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。     

Comparison of the Nuss and the Ravitch procedure for pectus excavatum repair: a meta-analysis

Purpose

Pectus excavatum is the most common chest wall deformity in children. Two procedures are widely applied—the Nuss and the Ravitch. Several comparative studies are published evaluating both procedures with inconsistent results. Our objective was to compare the Nuss procedure to the Ravitch procedure using systematic review and meta-analysis methodology.

Methods

All publications describing both interventions were sought through the Cochrane Central Register of Controlled Trials (CENTRAL) database, MEDLINE, and EMBASE. The statistical analysis was performed using RevMan 5 software. Odds ratios (OR) and weighted mean differences (WMDs) with 95% confidence intervals are presented.

Results

No randomized trials were identified. Nine prospective and retrospective studies were identified and were included in this study. There was no significant difference in overall complication rates between both techniques (OR, 1.75 (0.62-4.95); P = .30). Looking at specific complications, the rate of reoperation because of bar migration or persistent deformity was significantly higher in the Nuss group (OR, 5.68 (2.51-12.85); P = .0001). Also, postoperative pneumothorax and hemothorax were higher in the Nuss group (OR, 6.06 [1.57-23.48]; P = .009 and OR, 5.60 [1.00-31.33]; P = .05), respectively. Duration of surgery was longer with the Ravitch (WMD, 69.94 minutes (0.83-139.04); P = .05). There was no difference in length of hospital stay (WMD, 0.4 days (−2.05 to 2.86); P = .75) or time to ambulation after surgery (WMD, 0.33 days [−0.89 to 0.23]; P = .24). Among studies looking at patient satisfaction, there was no difference between both techniques.

Conclusions

Our results suggest no differences between the Nuss procedure vs the Ravitch procedure with respect to overall complications, length of hospital stay, and time to ambulation. However, the rate of reoperation, postoperative hemothorax, and pneumothorax after the Nuss procedure were higher compared to the Ravitch procedure. No studies showed a difference in patient satisfaction.     

Changes in Pulmonary Functions of Adolescents with Pectus Excavatum Throughout the Nuss Procedure

BackgroundWe aimed to determine the longitudinal changes in pulmonary functions of adolescents with Pectus Excavatum who underwent the Nuss procedure, the minimally invasive repair of pectus excavatum (MIRPE).MethodsLung function measurements were performed before bar implantation (T₀), at least six weeks to ten months after implantation (T_1a), at least eleven months to sixty-one months after bar implantation (T_1b) and at least two weeks after bar explantation (T₂).ResultsData of 114 patients (83.3% male) whose median age at implantation was 15.6 years and at explantation 18.7 years were analyzed. Shortly after implantation at T_1a a significant decline of vital capacity (VC; n = 82), forced vital capacity (FVC; n = 78) and forced expiratory volume in 1 second (FEV₁; n = 80) compared to T₀ was seen. At T_1b a significant decline for the residual volume (RV; n = 83), the residual volume/total lung capacity ratio (RV/TLC; n = 81), the total specific airway resistance (sRaw; n = 80) and the total airway resistance (Raw; n = 84) also compared to T₀ was measured. In the comparison of T_1b to T₂ a significant increase of VC, FVC (n = 67), FEV₁ (n = 69), TLC (n = 67) and a significant decrease of Raw (n = 66), sRaw, RV (n = 65) and the RV/TLC (n = 64) ratio could be observed. In the direct analysis between T₀ and T₂, after the explantation of the bar a significant increase in VC (n = 54), FVC (n = 52), and TLC (n = 55) and a significant decrease of RV (n = 51) and the RV/TLC index (n = 50), and in airway resistance parameters like Raw (n = 52) and sRaw (n = 51) could be detected.ConclusionsLung function values along with markers of airway resistance improve in patients after the complete procedure of MIRPE.Level of EvidenceLevel II.     

Postoperative opioid analgesic use after Nuss versus Ravitch pectus excavatum repair

Background/Purpose

Anticipated postoperative pain may affect procedure choice in patients with pectus excavatum. This study aims to compare postoperative pain in patients undergoing Nuss and Ravitch procedures.

Methods

A 5 year retrospective review was performed. Data on age, gender, Haller index, procedure, pain scores, pain medications, and length of hospital stay were collected. Total inpatient opioid administration was converted to morphine equivalent daily dose per kilogram (MEDD/kg) and compared between procedures.

Results

One hundred eighty-one patients underwent 125 (69%) Nuss and 56 (31%) Ravitch procedures. Ravitch patients were older (15.7 yo vs 14.6 yo, p = 0.004) and had a higher Haller index (5.21 vs 4.10, p = < 0.001). Nuss patients had higher average daily pain scores, received 25% more opioids (MEDD/kg 0.66 vs. 0.49, p = < 0.001), and received twice as much IV diazepam/kg. In the multivariate analysis, higher MEDD/kg correlated with both the Nuss procedure and older age in the Nuss group. Opioid administration did not correlate with Haller index or Nuss bar fixation technique. Increased NSAID administration did not correlate with lower use of opioids.

Conclusion

The Nuss procedure is associated with greater postoperative pain compared to the Ravitch procedure. Opioid use is higher in older patients undergoing the Nuss procedure, but is not associated with severity of deformity.     

Quality-of-life outcomes after surgical correction of pectus excavatum: a comparison of the Ravitch and Nuss procedures

Purpose

The purpose of this study was to compare clinical and health-related quality-of-life (HRQL) outcomes within a group of patients treated for pectus excavatum (PE).

Methods

A retrospective 3-year review of patients undergoing Nuss or Ravitch correction of PE was performed. Health-related quality-of-life assessment was performed using the Child Health Questionnaire (CHQ-CF87) and the 17-item Pectus Excavatum Evaluation Questionnaire, and results were compared between groups and with age-matched CHQ-CF87 normative data.

Results

Forty-three patients (39 males; 91%) underwent surgery; 19 (44%) by Nuss procedure. Duration of postoperative opioid analgesia and length of hospital stay (LOS) were significantly longer in Nuss patients. The overall survey response rate was 53%. The groups differed significantly in the CHQ on one item (Change in Health). On the Pectus Excavatum Evaluation Questionnaire, Nuss patients reported being “less bothered” by the appearance of their chest. Compared to Australian age-matched norms, the aggregate PE sample showed better scores for family activity domain and worse scores in mental health, general health perceptions, change in health, bodily pain, and self-esteem.

Conclusions

Patients undergoing surgery for PE by either Nuss or Ravitch procedure have similar clinical and HRQL outcomes, but as a group have poorer HRQL scores than age-matched population norms.     

When patients choose: comparison of Nuss, Ravitch, and Leonard procedures for primary repair of pectus excavatum

Background/Purpose

Pectus excavatum is a common chest wall deformity, and several procedures have been developed for its correction. We allow patients to choose among Leonard, Nuss, and Ravitch procedures. This study aimed to determine which procedure most patients select and the resultant outcomes.

Methods

Charts were reviewed of all pectus excavatum repairs performed for 4 years by a practice covering a university-based children's hospital. Procedure choice, operative time, length of stay, analgesia, fees, and complications were recorded.

Results

The Ravitch procedure was chosen by 60.9% of our patients, Leonard procedure by 23.9%, and Nuss procedure by 15.2%. Operative times were not significantly different among the groups. The mean length of stay was 2.2 days (Ravitch), 1.5 days (Leonard), and 3.9 days (Nuss) (P < .005). Epidural analgesia/patient-controlled analgesia pump requirements were 50% (Ravitch), 5% (Leonard), and 100% (Nuss). The mean charges were $27,414 (Ravitch), $18,094 (Leonard), and $43,749 (Nuss) (P < .05). The overall complication rate was 16.3%. The complications among each group were as follows: Ravitch, 14.3%; Leonard, 9.1%; and Nuss, 35.7%.

Conclusions

We allow patients to choose among Leonard, Ravitch, and Nuss procedures for repair of pectus excavatum. Most select the Ravitch procedure. Length of stay, fees, analgesic needs, and complication rate were highest among patients in the Nuss group; all of these variables were lowest in the Leonard group.     

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.     

儿童微创Nuss手术相关并发症的处理及预防

目的 总结微创Nuss手术治疗儿童漏斗胸的相关并发症的预防及处理原则.方法 2005年5月～2011年12月采用Nuss手术治疗280例漏斗胸患儿,其中8例为复发漏斗胸,5例合并心肺合并症,7例有胸部手术史.取两侧腋中线小切口,在胸腔镜的监视下,用穿通器将已塑形的钢板凸面朝下由左侧肋弓最高点经胸骨最低点拉至右侧肋弓最高点穿出,翻转钢板撑起凹陷的胸骨,固定钢板.结果 280例手术顺利,平均手术时间54 min(38～ 120 min).并发症发生率16.4％(46/280),其中早期并发症28例:心包穿孔3例,均退回并重置穿通器;肋间隙撕裂1例,重新选择肋间斜置钢板;心包炎1例,对症治疗好转;气胸12例,3例穿刺抽吸,3例闭式引流,6例未处理;胸腔积液7例,2例穿刺抽液,2例闭式引流,3例未处理;肺炎2例,予抗感染治疗后恢复;切口感染2例,换药处理后愈合.晚期并发症18例;切口无菌性囊肿3例,保守治疗好转;支架移位3例,均再手术纠正;疼痛造成获得性脊柱侧弯3例,理疗后1例恢复,2例未恢复;钢板金属过敏2例,分别提前取出固定片及支架;钢板压迫肋软骨3例,提前取出钢板;肋软骨过度增生4例,取钢板时加做肋骨截骨术.结论 早期诊断并及时处理是有效治疗Nuss手术相关并发症的关键.