儿童微创Nuss手术相关并发症的处理及预防

Treatment and Prevention of Complications Associated with Nuss Procedure For Children

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。

Objective To summarize the treatment and prevention of the complications associated with Nuss procedure for children.Methods From May 2005 to December 2011,280 children（male： 195;female： 85） with pectus excavatum undergoing Nuss procedure were reviewed retrospectively.The patients included 8 cases of recurrence,5 cases of other cardiothoracic diseases and 7 cases with thoracic operation history.The incision was made on the midaxillary line under thoracoscope.A shaping pectus bar was inserted under the sternum through small bilateral thoracic incisions under thoracoscope.The bar was inserted with the convexity facing posteriorly,then was turn over to raise the sternum to normal position.Results Nuss procedure was completed in all patients.The operation time ranged from 38 to 120 min（mean： 54 min）.The complications occurred in 46 cases（16.4%）,including 28 cases of early postoperative complications： pericardium injury in 3 cases,which required introducer resetting;intercostal muscle avulsion in 1 case,which needed the renewal of pectus bar;pericarditis in 1 case,who relieved after proper treatment;pneumothorax in 12 cases,including 3 cases of needle puncture aspiration,3 cases of closed drainage,and 6 untreated cases;pleural effusion in 7 cases,including 2 cases of needle puncture aspiration,2 cases of closed drainage,and 3 untreated cases;pneumonia in 2 cases,who recovered after anti-infection treatment;wound infection in 2 cases,which were healed by proper treatment.There were 18 cases of late postoperative complications： wound seroma in 3 cases,which improved after conservative treatment;bar displacement in 3 cases,which were corrected by second surgery;scoliolosis caused by persistent pain in 3 cases,one recovered and the other two did not recover after physical treatment;bar allergy in 2 cases,and fixed plate and support were removed in advance respectively;costal cartilage constricted by pectus bar in 3 cases,and the shaping pectus bar was removed in advance;and hyperplasia of costal cartilage in 4 cases and osteotomy of the ribs was performed when removing the pectus bar.Conclusion Early diagnosis and timely management are the keys to dealing with complications related to Nuss procedure.