经胸骨正中切口直视Nuss手术治疗先天性心脏病合并漏斗胸的单中心经验

Open Nuss procedure via median sternotomy for pectus excavatum with congenital heart disease

目的探究经胸骨正中切口实施直视Nuss手术治疗先天性心脏病(先心病)合并漏斗胸的优化策略。方法回顾上海交通大学医学院附属上海儿童医学中心2017年1月至2021年11月, 接受经胸骨正中切口直视Nuss手术的25例先心病合并漏斗胸患儿。同期纠正心脏解剖畸形和漏斗胸组(A组)9例, 身高(121.7±28.0)cm, 体质量(22.2±14.0)kg, 年龄(7.65±4.08)岁, Haller指数3.99±1.37;先心病术后再次行漏斗胸Nuss手术组(B组)16例, 身高(130.9±27.2)cm, 体质量(26.5±14.3)kg, 年龄(8.82±4.09)岁, Haller指数4.18±0.97。术前分别通过超声心动图和计算机断层扫描评估所有患儿的心脏解剖情况、心功能和漏斗胸严重程度。分别记录两组患儿性别、术前漏斗胸外观、合并先心病种类、有无分离胸骨后粘连情况以及漏斗胸手术与先心病手术间隔年限。分别记录两组患儿的手术时间、住院天数、手术效果、术中不良事件、术后并发症以及随访情况。结果 25例患儿均顺利完成手术, 无术中不良事件, A组1例术后伤口感染。A组手术(3.78±1.54)h, 显著长于B组(2.19±0.94)h, P<0.05;两组术后呼吸机运用差异无统计学意义[(22.50±45.64)h对(4.18±1.41)h, P=0.263];A组患儿ICU滞留显著长于B组[(4.00±6.42)天对(1.13±0.34)天, P<0.05], 两组住院天数差异无统计学意义[(16.00±15.18)天对(9.19±2.31)天, P=0.419]。两组14例术后(27.9±11.3)个月拔除钢板, Haller指数2.48±0.49。术后超声心动图示左心室射血分数与术前差异无统计学意义(0.663±0.028对0.659±0.038, P=0.533)。肺功能FVC和FEV1均较术前有明显改善[(87.2±3.9)%对(84.1±8.2)%]。手术效果良好。结论对于先心病合并漏斗胸的患儿, 经仔细评估可以施行一期或者分期的个体化直视Nuss手术。胸骨正中切口和优秀的再次开胸技术有利于松解胸骨后粘连, 并有效避免心脏出血等严重并发症, 手术效果良好。

Objective To optimize the strategy of Nuss procedure with open approach via median sternotomy for pectus excavatum(PE)with congenital heart disease(CHD).Methods 25 PE patients with CHD treated in our center from January 2017 to November 2021 were reviewed and divided into two groups.The CHD surgery and open Nuss procedure with median sternotomy were performed concomitantly in 9 cases(group A),whose height of(121.7±28.0)cm,weight of(22.2±14.0)kg,age of(7.65±4.08)years old,and Haller index of 3.99±1.37.16 cases underwent open Nuss procedure via median re-sternotomy after congenital heart surgery(group B),whose height of(130.9±27.2)cm,weight of(26.5±14.3)kg,age of(8.82±4.09)years old,and Haller index of 4.18±0.97.The cardiac anatomy,cardiac function and the severity of PE of all patients were evaluated by echocardiography and computed tomography preoperatively.The preoperative gender,appearance of PE,types of associated CHD,retrosternal adhesion and the interval between open Nuss procedure and CHD surgery were collected.The details of operation,hospital stay,intraoperative adverse events,postoperative complications and follow-up were collected.Results All the operations were accomplished successfully in 25 children.No intraoperative complications occurred.One had a postoperative wound infection in group A.The operation time of group A was significantly longer than that of group B[(3.78±1.54)h vs.(2.19±0.94)h,P<0.05].There was no significant difference in the mechanical ventilation time between the two groups[(22.50±45.64)h vs.(4.18±1.41)h,P=0.263].The ICU stay of group A was significantly longer than that of group B[(4.00±6.42)days vs.(1.13±0.34)days,P<0.05].There was no significant difference in the length of hospital stay between the two groups[(16.00±15.18)days vs.(9.19±2.31)days,P=0.419].The Nuss bar was removed in 14 cases of the two groups,with a interval of(27.9±11.25)months after open Nuss procedure,the postoperative Haller Index was 2.48±0.49.There was no difference of LVEF in postoperative and preoperative echocardiography(0.663±0.028 vs.0.659±0.038,P=0.533).The FVC and FEV1 were significantly improved compared with before operation[(87.2±3.9)%vs.(84.1±8.2)%].The outcome was good.Conclusion For PE patients with CHD,one-stage or staged individualized Nuss procedure with open approach via median sternotomy can be performed after careful preoperative evaluation.A skillful median re-sternotomy and widely dissecting retrosternal adhesion between sternum and anterior wall of heart are necessary to avoid serious intraoperative complications such as massive heart bleeding and ensure good sternal elevation.