Nuss手术与改良Ravitch手术治疗小儿漏斗胸疗效的对比研究

目的比较Nuss手术与改良Ravitch手术治疗小儿漏斗胸的疗效。方法对比分析我院1992年1月-2010年10月采用改良Ravitch手术与Nuss手术治疗小儿先天性漏斗胸88例临床资料。2组年龄无差异。改良Ravitch手术（R组）45例,骨膜内切除变形肋软骨,胸骨截骨,分离胸骨后及两侧间隙,用克氏针将凹陷胸骨抬高固定;Nuss手术43例（N组）,腋中线小横切口,支撑钢板预弯,胸腔镜下,用引导器将钢板经胸膜外引入对侧,翻转钢板撑起下陷胸骨,固定钢板。结果与R组相比,N组切口短[（3.85±0.71）cm vs.（9.67±2.80）cm,t=13.227,P=0.000],出血量少[（5.7±1.8）ml vs.（63.8±54.8）ml,t=6.942,P=0.000],输血患者比例少[0%（0/43）vs.42.2%（19/45）,P=0.000],手术时间短[（59.4±8.9）min vs.（167.5±57.3）min,t=12.222,P=0.000],总住院时间短[（9.1±2.5）d vs.（18.9±5.1）d,t=11.469,P=0.000],术后住院时间短[（4.7±1.6）d vs.（11.9±2.7）d,t=15.332,P=0.000]。并发症发生率R组22.2%（10/45）,N组30.2%（13/43）（χ2=0.731,P=0.393）。2组88例随访3个月-9年,总满意率R组95.6%（43/45）,N组97.7%（42/43）（χ2=0.000,P=1.000）,其中36例〉3年,满意率R组90.9%（20/22）,N组92.9%（13/14）（χ2=0.000,P=1.000）。结论 Nuss手术微创优势明显,中期疗效满意,可作为治疗小儿漏斗胸的首选术式。严重的非对称性漏斗胸尤其伴严重的多发肋骨畸形者,以及不具备实施Nuss手术条件的医疗单位,仍可以采用改良Ravitch手术治疗小儿漏斗胸。     

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。     

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.     

Complications associated with the Nuss procedure: continued evolution of the learning curve

BACKGROUND: We report unusual and/or significant complications encountered during and after the Nuss Procedure for pectus excavatum. METHODS: This was a retrospective review that was approved by the institutional review board, with parental consent. RESULTS: Seven patients had unique and/or significant complications as follows: (1) laceration of an internal mammary artery during bar placement requiring emergent minithoracotomy; (2) hemopericardium 10 weeks postoperatively after blunt chest trauma requiring exploration of the pericardium and clot evacuation; (3) almost complete recurrence of the pectus excavatum deformity immediately after bar removal; (4 and 5) immediate/early postoperative bar displacement requiring re-operation and placement of 2 bars each; and (6 and 7) almost complete neo-ossification of the Nuss bar, making removal challenging. CONCLUSIONS: The Nuss procedure has met with near-universal acceptance. Complications are just being reported. We describe 7 events to add to the evolving literature as the entire pediatric surgery community participates in the initial learning curve.     

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。     

Nuss手术并发症的处理及预防

目的 探讨微创Nuss手术治疗漏斗胸的手术并发症,预防方法及处理原则.方法 2002年7月至2008年7月共行613例Nuss手术,其中55例为复发的漏斗胸,116例为有合并症的漏斗胸.35例出现并发症,占5.71%.分析术中并发症和术后并发症出现的原因,总结处理方法和预防的原则.结果 613例均顺利完成手术,手术时间25～300 min,术中出血1～200 ml.术中并发症10例,包括心包损伤4例、心脏损伤1例、膈肌穿通肝脏损伤2例、肋间肌撕脱2例,肋间血管损伤1例;均在术中得到妥善处理.术后并发症25例,包括支撑架移位3例、液气胸14例、长期疼痛5例(疼痛造成脊柱侧弯3例)、引流管断入胸腔1例、金属排斥和伤口感染各1例;支撑架移位、支撑架排斥和引流管断入胸腔各1例均再手术后痊愈,其余保守治疗治愈.结论 Nuss手术虽然并发症发生率较高但多属于轻微并发症,随着对并发症的认识和技术的进步,并发症的发生率将大大降低.     

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.     

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.     

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。     

Evaluation of the Nuss procedure using pre- and postoperative computed tomographic index

Background

Objective assessment of the chest in patients with pectus excavatum after the Nuss procedure has not been published. This study evaluated the results of the Nuss procedure using computed tomographic (CT) index (CTi).

Methods

We have performed the Nuss procedure in 382 patients since 1998, and 150 patients who underwent bar removal were included in this study. Computed tomographic scans were obtained before the Nuss procedure and after bar removal, and then preoperative CTi (pre-CTi) and postoperative CTi (post-CTi) were calculated. Computed tomographic scans of 62 age-matched patients without chest deformity were collected as controls. Patients were divided at 10 years of age into the younger and older groups, and groups with mild and severe deformity were defined using a pre-CTi value of 5 as border. These CT indices were compared and statistically analyzed.

Results

Mean pre-CTi in all cases was 5.97 ± 3.31 and improved to 3.08 ± 0.64. Postoperative CTi was not significantly different from that of the control (2.47 ± 0.32, P = .17). In the group with mild depression, pre-CTi was 4.15 ± 0.62, and post-CTi was 2.88 ± 0.50. Preoperative CTi in the group with severe deformity (7.44 ± 3.82) improved to 3.25 ± 0.69. Postoperative CTi values between the severe and mild groups were not significantly different (P = .75). Computed tomographic index of the young group improved from 6.20 ± 3.58 to 2.93 ± 0.49 and in older group from 5.50 ± 2.64 to 3.40 ± 0.79. These 2 post-CTi values were not significantly different (P = .73).

Conclusion

Postoperative CT scan could provide objective evaluation of sternal elevation. Mean CTi after the Nuss procedure was statically equivalent to that of the control cohort. Good sternal elevation can be achieved with the Nuss procedure regardless of the severity of chest depression or age.     

Development of supravalvular pulmonary artery stenosis following a Nuss procedure

We report a case of a 13-year old girl with pectus excavatum who had a Nuss procedure and two years later a new cardiac murmur appeared which on investigation was diagnosed as supravalvular pulmonary artery stenosis. Following removal of the Nuss bar the stenosis resolved.     

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.     

Erosion of the Nuss bar into the internal mammary artery 4 months after minimally invasive repair of pectus excavatum

The minimally invasive repair of pectus excavatum has become increasingly popular. Life-threatening complications have included bleeding and cardiac perforation. There have been a number of delayed cases of bleeding, many of which never demonstrated a clear source. We present a case of a delayed acute bleed from the Nuss bar eroding into the internal mammary artery 4 months after bar placement.     

Cardiopulmonary resuscitation in patients with a Nuss bar--a case report and review of the literature

Pectus excavatum (PE) is a common chest wall deformity that may produce a variety of physiological and psychological effects in children and adolescents. In addition, some of these patients have associated cardiac diseases (ie, mitral valve prolapse and Marfan syndrome). Recently, a minimally invasive surgical repair of PE that requires sternal bar placement has become increasingly frequent to enhance patients' cardiopulmonary functioning as well as their self-esteem. However, despite this innovative technique, it is possible for such patients to have a cardiac arrest while their sternal bar is in place. Whether the presence of a metal bar on the underside of their sternum may hinder resuscitative chest compressions (cardiopulmonary resuscitation) is an issue that concerns us, our patients, and their families; the answer requires further investigation. We present a 21-year-old man with PE who underwent a minimally invasive pectus repair but had a fatal cardiac event before bar removal. Paramedics conducting cardiopulmonary resuscitation on the patient later reported that they were unable to deliver effective cardiac compressions and that the sternal bar may have contributed to this.     

Multivariate analysis of risk factors for Nuss bar infections: A single center study

Background/Purpose

Our previously published data suggested several risk factors for infection after the Nuss procedure. We aimed to further elucidate these findings.

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。     

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。     

漏斗胸患儿手术前后心功能测定及其意义

目的　探讨漏斗胸患儿手术前后心脏功能的变化。　方法　用超声心动图测定４１ 例漏斗胸患儿术前、术后的心脏功能,并选择年龄、性别、身高、体重相同的正常儿童４１ 例作对照。　结果　病例组患儿术前射血分数与平均左心室周径向心缩短率与对照组相比有所降低（ Ｐ＜ ０－０１） ;术后３ 个月复查时其每搏输出量增加;长期随访（ 平均４－７年） 发现患儿术后射血分数、平均左心室周径向心缩短率与每搏输出量较术前有所上升（ Ｐ＜ ０－０１） ,而且这些指标与对照组相比差异无显著性（ Ｐ＞ ０－０５） 。　结论　漏斗胸患儿术前心脏功能有损害,术后心功能可逐步恢复正常。     

Modified Nuss procedure with a novel steel bar in patients with pectus excavatum post-congenital heart surgery

 Open in a separate windowOBJECTIVESPectus excavatum (PE) can be secondary in patients who underwent sternotomy for cardiac surgery. Retrosternal adhesions increase the complexity and risk of traditional Nuss repair. Thus, we summarized the outcomes of our modified Nuss procedure using a newly designed bar.METHODSA retrospective analysis was performed on 35 patients who underwent modified PE repair after open heart surgery from January 2011 to July 2019. The surgery was performed using a novel bar with no need for intraoperative reshaping and rotation, assisted by thoracoscopy and subxiphoid incision when necessary.RESULTSThere were 19 males and 16 females with a median age of 5.3 years (interquartile range, 4.1–10.9) at PE repair. All patients underwent the modified procedure uneventfully with no death. The median operating time was 70 min. Twenty-nine (82.9%) patients required subxiphoid incision assistance. There was 1 case (2.8%) with unexpected sternotomy due to intraoperative bleeding. The median length of postoperative hospital stay was 4 days. During the median 3.5 years of follow-up, no bar dislocation was found and 30 (85.7%) patients had their bars removed with no recurrence recorded. After PE repair, the Haller index improved significantly (2.6 ± 0.4 vs 4.9 ± 1.3, P < 0.05) and further decreased till the time of bar removal (2.5 ± 0.4 vs 2.6 ± 0.4, P < 0.05). All patients were satisfied with the cosmetic outcome.CONCLUSIONSThe novel bar can be placed and removed easily with a low rate of adverse events. This modified Nuss procedure seems to be a safe, effective and convenient approach for the management of PE after cardiac surgery.