Nuss手术与改良Ravitch手术治疗小儿漏斗胸疗效的对比研究

Compararison of Modified Ravitch and Nuss Procedure for Pediatric Pectus Excavatum

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。

Objective To compare the results of modified Ravitch and Nuss procedure in the management of pediatric pectus excavatum.Methods Eighty-eight cases of pectus excavatum treated in our hospital from January 1992 to October 2010 were reviewed retrospecively.Of the 88 cases,45 recieved modified Ravitch procedures（Group Ravitch）,in which the deformed cartilage was resected and the sternum was elevated and fixed retrosternally with a Kirschner wire after transverse sternostomy;and 43 patients underwent Nuss procedures（Group Nuss）,in which a Nuss bar was placed extrapleurally behind the sternum with VATS.ResultsCompared with Ravitch group,Nuss group had smaller incision [（3.85±0.71） cm vs.（9.67±2.80） cm,t=13.227,P=0.000],less blood loss[（5.7±1.8） ml vs.（63.8±54.8） ml,t=6.942,P=0.000],and shorter operation time [（59.4±8.9） min vs.（167.5±57.3） min,t=12.222,P=0.000],hospital stay [（9.1±2.5） d vs.（18.9±5.1） d,t=11.469,P=0.000],and postoperative hospital stay [（4.7±1.6） d vs.（11.9±2.7） d,t=15.332,P=0.000].The rate of postoperative complications were 22.2%（10/45） and 30.2%（13/43） respectively in groups Ravitch and Nuss（χ2=0.731,P=0.393）.After a follow-up for three months to nine years,the rate of satisfied correction was 95.6%（43/45） and 97.7%（42/43） respectively in groups Ravitch and Nuss（χ2=0.000,P=1.000）.Among the patients,36 cases were followed up for more than 3 years,which showed a satisfied correction rate of 90.9%（20/22） and 92.9%（13/14） respectively in groups Ravitch and Nuss（χ2=0.000,P=1.000）.Conclusions Nuss procedures are superior to modified Ravitch in minimal invasion and mid-term efficacy,therefore it is the first option in the management of pediatric pectus excavatum.However,Ravitch procedure shall be reserved for patients with asymmetric pectus excavatum and surgeons who cannot perform Nuss procedures.