Child pectus excavatum: Correction by minimally invasive surgery
Child pectus excavatum: Correction by minimally invasive surgery
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DOI：
10.1016/j.otsr.2009.03.001
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发表时间：
2009-05-01
影响因子：
2.3
通讯作者：
Bollini, G.
中科院分区：
文献类型：
--
作者：
Felts, E.;Jouve, J. -L.;Bollini, G.
导论. - 漏斗胸（PE）是一种先天性畸形，主要是由于外观不好看，更罕见的是由于压迫问题。经典的治疗方法包括填充空洞或开放胸重建（Ravitch技术）。或者，Nuss描述的治疗方法是在胸腔镜引导下放置胸骨后金属棒抬高胸骨。我们提出了一系列的25名儿童手术使用这种技术的初步结果。- Nuss描述的微创手术是治疗PE的有效手术策略。材料与方法。- 2004年2月至2007年4月期间，由同一名外科医生对25名患者进行了手术。这些患者中有19例表现为纯粹的美容适应症。其他6名患者被认为患有更严重的PE，伴有心肺反应。在该组中，有2例马凡氏综合征和2例既往心胸手术史的患者。该技术一直包括通过两个侧切口放置胸骨后杆。21例均在胸腔镜引导下行右肺旷置术。在4例特别严重的病例中，需要剑突下入路，无需内镜引导。采用Haller指数评价病变的严重程度。所有患者均接受定期临床随访（3周、3个月、然后每6个月一次）;疼痛评估、对美容效果的满意度以及呼吸功能的感知改善是本次随访的标准。- 24例患者的美容结果被判定为阳性。1例患者不满意（因为使用单个植入物导致形状不对称）。5例患者出现轻微并发症，对外观或功能结果无影响。1例继发性棒移位需要在第15天进行翻修。翻修后，进展不复杂（第7天出院，3周时恢复活动）。最后，植入后延迟一到两年取出硬件。截至今天，13名患者已取出硬件，没有并发症或损失的初步结果。- Nuss技术的最初适应症仍然是7至14岁儿童的对称性PE。非实质性的疤痕使该技术在纯粹的美容形式的条件有价值。在此基础上，我们的技术已经发展到一定的调整，这取决于病变的严重程度和病因。文献中报道最多的并发症是继发性移位的酒吧。这个问题很容易通过将杆连接到肋来控制。多年来，我们改进了种植体设计，以提高其耐受性和稳定性。在不对称形式的PE中，植入两个棒提供了更好的疗效。当存在主要形式或有心肺问题病史时，我们建议剑突下短切口以释放胸膜和心包粘连，无需胸腔镜引导。通过这些简单的调整，该技术在美容适应症中获得了可靠性，并且其使用可以扩展到特定形式，如胶原病或术后畸形。证据等级：IV级。治疗研究。(C)2009年Elsevier Masson SAS。All rights reserved.
Introduction. - Pectus excavatum (PE) is a congenital deformity essentially responsible for an unattractive aspect, much more rarely for compression problems. The classical treatments consist either in filling the excavation or in open thoracic reconstruction (the Ravitch technique). Alternatively, the treatment described by Nuss raises the sternum with a retrosternal metallic bar placed under thoracoscopic guidance. We present the preliminary results of a series of 25 children operated on using this technique.Hypothesis. - The minimally invasive procedure described by Nuss is a valid surgical strategy to treat PE.Materials and methods. - Twenty-five patients were operated on between February 2004 and April 2007 by the same surgeon. Nineteen of these patients presented a purely cosmetic indication. The six other patients were considered to have a more severe form of PE, with cardiorespiratory repercussions. In this group, there were two cases of Marfan syndrome and two patients presenting a history of previous cardiothoracic surgery. The technique has always consisted in placing a retrosternal bar through two lateral incisions. The surgery was always performed with right lung exclusion and was guided by thoracoscopy in 21 cases. In four particularly severe cases, a subxiphoid approach was required, making endoscopic guidance unnecessary. The severity of the lesion was evaluated by the Haller Index. All the patients had regular clinical follow-up (at three weeks, three months, and then every six months); assessment of pain, satisfaction with the cosmetic results, and perceived improvement in respiratory function were the criteria used for this follow-up.Results. - The cosmetic result was judged to be positive by 24 patients. One patient was dissatisfied (because of the asymmetrical shape resulting from the use of a single implant). Five patients presented minor complications with no repercussions on the cosmetic or functional result. One case of secondary bar displacement required revision on day 15. Following this revision evolution was uncomplicated ( discharge on day 7 and activities resumed at three weeks). Finally, the hardware was removed at a delay after implantation ranging from one to two years. As of today, 13 patients have had their hardware removed with no complications or loss of the initial result.Discussion. - The original indication of the Nuss technique remains symmetrical PE in seven to 14-year-old children. The insubstantial scarring makes the technique valuable in the purely cosmetic forms of the condition. Based on this series, our technique has evolved toward certain adjustments depending on the severity and the etiology of the lesion.The most reported complication in the literature is secondary displacement of the bars. This problem is easily controlled by attaching the bar to a rib. Over the years, we have modified the implant design so as to improve its tolerance and stability. In asymmetrical forms of PE, implanting two bars has provided better efficacy. When a major form is present or when there is a history of cardiorespiratory problems, we recommend a short subxiphoid incision to release the pleural and pericardial adherences, precluding the need for thoracoscopic guidance.With these simple adjustments, this technique gains in reliability for cosmetic indications and its use can be extended to specific forms such as collagenosis or postoperative deformities.Level of evidence: Level IV. Therapeutic Study. (C) 2009 Elsevier Masson SAS. All rights reserved.