修改後的手術有效地修補漏斗胸


  Aug. 18, 2004 - 根據一項發表於8月號手術學誌(Annals of Surgery)的試驗結果顯示,一種修改後的Ravitch修補手術僅切除少數軟骨,對所有年紀、不同形式的漏斗胸都是有效的,而且術後胸腔是穩定的、術後疼痛相對地較少、復原快,不論是生理上或外觀上都有良好的預後。
  
  加州大學洛杉磯分校醫學院外科部Eric W. Fonkalsrud醫師指出,過去60年來,許多修改過的Ravitch手術已經被用於修補漏斗胸,但是術後併發症與修補成果卻是不一致的;最佳的修補並不需要廣泛地骨膜下肋軟骨切除,及將肋骨膜鞘從胸骨分離。
  
  在一年期間,75位病患(58位男性、17位女性),年齡從7到51歲(平均18.4歲),接受漏斗胸變形修補手術;某些病患患有不對稱(34位)或再發性變形(6位)漏斗胸;所有病患於輕微運動時都有呼吸困難、耐力降低、心搏過速、前胸不適等症狀;電腦斷層與放射線攝影顯示不同程度的心臟錯置進入左胸情況,平均凹陷嚴重指數為4.9(範圍從3.7-14.2﹔正常平均為2.5)。
  
  手術修補牽涉到一種高度修改後的Ravitch手術,同時僅有少數軟骨被切除;Fonkalsrud醫師解釋,打開變形的肋軟骨後,將會切除一片靠近胸骨中間且位於幾乎正常形狀肋骨高度的骨頭,使得軟骨能夠以最小力量提升到理想高度;大部分病患接受橫向胸骨前骨骼切除術。
  
  平均手術時間為174分鐘(±26分鐘)、平均失血量為88毫升;66位病患接受胸骨下支撐,其中9位病患(小於12歲或大於40歲)支撐物置於胸骨前,52位病患修補後大約6個月移除支撐物;平均手術時間為18分鐘(±6分鐘)。
  
  術後大部分病患胸腔是穩定的,病患住院時間很短(平均2.7天)且僅有些微術後疼痛;除了2位外,其餘病患都很快地(12天內)回到工作崗位。
  
  4個月內,所有病患運動耐受度都有改善,包括呼吸困難減少、持久性與耐力增加、且前胸疼痛或不適的狀況也都減少;而平均追蹤8.2個月間,除了1位病患外,其於病患認為他們的手術結果是「很好」或「傑出」。
  
  術後雖有併發症,但並不需要治療,這些併發症包括短暫性肋間滲液(3位)、小範圍左胸氣胸(1位)、及支撐物些微地移位(2位);另有輕微到中度的增生性疤痕(9位),被注入triamcinolone溶液。
  
  Fonkalsrud醫師指出,接受比較局部的開胸修補,配合切除少數軟骨的病患恢復地普遍比使用修改後Ravitch技術的來得快,開刀時間短、術後胸腔穩定、相對較輕微的疼痛、平均住院天數為2.7天、以及早點回到工作崗位,相較於之前的經驗,都是這項手術的特色。
  
  研究人員表示,在矯正長期且不對稱變形及胸腔前後狹窄病患,局部修補是成功的,因為它可以重建一個圓形輪廓;目前,已經有6位病患接受不同的局部開胸修補來成功地矯正再發性漏斗胸變形。
  
  Fonkalsrud醫師總結指出,相較於現在所提到的技術,普遍使用的修改後Ravitch修補術顯然並未提供更多好處,可能需要更長期的追蹤,以確認這些初期結果是否會長久地維持下去。

Modified Open Surgical Repair<

By Yael Waknine
Medscape Medical News

Aug. 18, 2004 — A modified Ravitch repair with minimal cartilage resection is effective for all variations of pectus excavatum (PE) in patients of all ages, resulting in a stable postoperative chest wall, relatively mild postoperative pain, and a short recovery with good physiologic and cosmetic results, according to a study published in the August issue of the Annals of Surgery.

"A wide variety of modified techniques of the Ravitch repair for PE have been used over the past 5 decades, with the complications and results being inconsistent," writes Eric W. Fonkalsrud, MD, from the Department of Surgery at the University of California at Los Angeles School of Medicine. "Extensive subperiosteal costal cartilage resection and perichondrial sheath detachment from the sternum may not be necessary for optimal repair."

During a one-year period, 75 consecutive patients (58 men, 17 women) aged seven to 51 years (mean, 18.4 years) underwent repair of PE deformities. Some patients had asymmetric (n = 34) or recurrent (n = 6) deformities. All patients had symptoms of dyspnea with mild exercise, reduced endurance, tachycardia, and anterior chest discomfort. Computed tomography (CT) and radiographs showed varying degrees of displacement of the heart into the left chest. Mean pectus severity index among patients was 4.9 (range, 3.7 - 14.2; normal mean, 2.5).

Operative repair involved a highly modified Ravitch technique with minimal cartilage resection. "After exposing the deformed costal cartilages, a short chip was resected medially adjacent to the sternum and laterally at the level where the chest had a near normal contour, allowing the cartilage to be elevated to the desired level with minimal force," Dr. Fonkalsrud explains. "A transverse anterior sternal osteotomy was used on most patients."

Mean operative time was 174 minutes (± 26 minutes) and mean blood loss was 88 mL. A substernal support strut was used in 66 patients; in nine patients (younger than 12 years or older than 40 years) the strut was placed anterior to the sternum. Struts were removed approximately six months after repair on an outpatient basis in 52 patients; mean operative time was 18 minutes (± 6 minutes).

The chest wall was stable in most patients immediately after surgery. Patients were hospitalized for a short time (mean, 2.7 days) and experienced mild postoperative pain. All but two returned to school or work relatively early, within 12 days.

Within four months, all patients showed improvement in exercise tolerance: dyspnea decreased, stamina and endurance increased, and anterior chest pain/discomfort were reduced. At a mean follow-up of 8.2 months, all but one patient considered their results to be "very good" or "excellent."

Postoperative complications did not require therapy and included transient pleural effusion (n = 3), small left pneumothorax (n = 1), and slight movement of the support strut (n = 2). Mild to moderately hypertrophic scars (n = 9) were injected with triamcinolone solution.

"Patients recover more quickly from the less extensive open repair with minimal cartilage resection than with the commonly used variations of the modified Ravitch repair, as noted by the short operating time, the stable postoperative chest, the relatively mild postoperative pain, the mean hospital stay of 2.7 days, and the early return to school or work, compared to our previous experience," Dr. Fonkalsrud points out.

The less extensive repair was successful in correcting long and asymmetric deformities and for patients with a very narrow anterior to posterior diameter of the chest, it permitted construction of a rounded contour, according to the author. Currently, six patients have undergone successful correction of recurrent PE deformities using variations of the less extensive open repair.

"There appears to be no advantage to the [commonly used] modifications of the more extensive Ravitch repair compared with the presently described technique," Dr. Fonkalsrud concludes, noting that longer follow-up will be needed to determine whether these initial results will be maintained over time.

The author reports no pertinent financial disclosures.

Ann Surg. 2004;240:231-235

Reviewed by Gary D. Vogin, MD

    
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