非胸腔镜辅助微创Nuss手术矫治复发漏斗胸

NON-THORACOSCOPIC MINIMALLY INVASIVE NUSS PROCEDURE FOR CORRECTION OF RECURRENT PECTUS EXCAVATUM

目的探讨非胸腔镜辅助微创Nuss手术治疗复发漏斗胸的有效性和治疗经验。方法2003年7月-2007年11月,手术治疗21例复发漏斗胸患者。其中15例行非胸腔镜辅助微创Nuss术(复发Nuss组),男13例,女2例;年龄(13.31±4.21)岁;CT示胸廓指数3.98±0.94;初次手术后凹陷复发时间<1年2例,1～3年4例,3～5年7例,>5年2例。6例行改良Ravitch术(复发Ravitch组),男5例,女1例;年龄(13.67±2.23)岁;胸廓指数3.92±1.01;初次手术后凹陷复发时间<1年2例,1～3年1例,3～5年3例。另有同期初次行非胸腔镜辅助微创Nuss术治疗119例漏斗胸患者(初次Nuss组),男95例,女24例;年龄(7.79±3.59)岁;胸廓指数4.61±1.36。复发Nuss组、复发Ravitch组年龄及胸廓指数与初次Nuss组比较,差异有统计学意义(P<0.05);复发Nuss组及复发Ravitch组比较,差异无统计学意义(P>0.05)。结果3组患者均顺利完成手术,术中无死亡、大出血及胸腔脏器损伤等严重并发症发生。初次Nuss组及复发Nuss组手术时间、术中出血量及术后入院时间与复发Ravitvh组比较,差异有统计学意义(P<0.05);初次Nuss组与复发Nuss组比较,差异无统计学意义(P>0.05)。术后患者均获随访,随访时间1个半月～37个月,平均11.2个月。除初次Nuss组1例发生钢板移位及2例出现缝线反应再次入院治疗外,其余患者均恢复良好,胸廓无矫形度丢失,运动耐力提高,气短、易疲劳症状改善,抑郁、孤独感减轻或消失。检查示复发Nuss组、复发Ravitch组及初次Nuss组术后胸廓指数分别为2.58±0.31、2.77±0.48及2.52±0.34,与术前比较,3组差异均有统计学意义(P<0.05)。结论复发漏斗胸再次手术矫正虽较初次手术更困难,但只要掌握手术原则、技巧,仔细操作,非胸腔镜辅助下行Nuss手术二次矫正仍然是安全有效的。

Objective To assess the efficacy and summarize the treatment experience in correction ot recurrent pectus excavatum by the non-thoracoscopic minimally invasive Nuss procedure. Methods From July 2003 to November 2007, 21 patients with recurrent pectus excavatum were treated with surgical repairs. Among them, there were 15 patients who underwent a Nuss procedure （the recurrent Nuss group）, 13 males and 2 females, aged （13.31 ± 4.21） years old, and the preoperative CT scan showed the mean Haller index was 3.98 ± 0.94. The recurrence time of the depression after the primary operation was different： 2 patients with less than 1 year, 4 with 1-3 years, 7 with 3-5 years and 2 with over 5 years. There were 6 patients who underwent a modified Ravitch procedure （the recurrent Ravitch group）, 5 males and 1 female, aged （13.67 ＋ 2.23） years old, and the mean Hailer index was 3.92 ± 1.01. The recurrence time of the depression after the primary operation was as follows： 2 patients with less than 1 year, 1 with 1-3 years and 3 with 3-5 years. Another 119 patients had a primary Nuss procedure in the same period （the primary Nuss group）, 95 males and 24 females, aged （7.79 ± 3.59） years old, and the mean Haller index was 4.61 _＋ 1.36. In terms of the age and the Haller index, there was significant difference between the recurrent Nuss group as well as the recurrent Ravitch group and the primary Nuss group （P 〈 0.05）, but there was no significant difference between the recurrent Nuss group and the recurrent Ravitch group （P 〉 0.05）. Results All the patients were performed with the surgery successfully without any severe complications. The operation time, blood loss and postoperative hospitalization time of the recurrent Nuss group and the primary Nuss group were significantly less than those of the recurrent Ravitch group （P 〈 0.05）, but there was no significant difference between the recurrent Nuss group and the primary Nuss group （P 〉 0.05）. All the patients were followed up for 1.5-37.0 months （11.2 months on average）. Except for 1 with plate displacement and 2 with suture reaction in the primary Nuss group who were readmitted to hospital, the other patients recovered well. The patients had perfect thoracic appearances with increased exercise tolerance and had a significantly improved psychological condition and an active social participation because of their improved appearances. The postoperative mean Haller index was 2.58 ± 0.31, 2.77 ±0.48 and 2.52 ± 0.34 in the recurrent Nuss group, the recurrent Ravitch group and the primary Nuss group, respectively, with significant difference compared with the preoperative mean Hailer index in each group （P 〈 0.05）. Conclusion Although the recurrent pectus excavatum repairs are technically more challenging than the primary surgery, the non-thoracoscopic Nuss procedure for reoperative correction is a safe, effective and reliable method.