因長期效果良好, 微創手術治療漏斗胸已被廣為接受, 近年來的技術改進, 如配合胸腔鏡之使用及固定片, 肋骨縫合固定及新的儀器設計等, 也降低了併發症發生率.
不同於需肋骨切除及胸骨折斷術等傳統手術方式, 微創手術失血量少, 手術時間短, 且不會造成胸壁纖維化等問題. 同時病友們也可更早回復正常生活. 尤其是對兒童, 無切除組織的方式, 不會造成胸壁的纖維化. 其他如吸盤或胸骨下置入磁鐵等其他微創手術方法及凸胸(雞胸)也多以背架方式取代廣泛性切除的傳統方式了.
INDICATIONS FOR SURGERY 手術適應症
無症狀的輕微至中度凹陷病人可先追踨檢查, 有症狀的及有明顯凹陷的病人, 需檢查心肺壓迫情形.
Best Age for Operation:手術的最佳時機
最好是在青春期前, 不但矯治效果最佳, 也不容易復發.同時心肺也能有足夠的空間生長. 近年來有些報告在20-50歲手術都有很好的結果.
手術後, 如能以深呼吸及常規地有氧運動, 刺激肺部, 可減少復發率. 同時, 矯正板移除後, 也要注意挺胸姿勢的保持, 可讓復凹率降至最低.
手術的適應症為符合下列二項:
1. 凹陷指數大於3.25.
2. 心臟呈現受壓迫, 位移, 二尖瓣脫垂, 心雜音, 及傳導障礙.
3.肺功能有限制性/阻塞性障礙.
4. 以前手術失敗病例
� MINIMALLY INVASIVE TECHNIQUES
在使用了胸腔鏡後, 我們在九百個手術中沒有發生過任何心或肺的傷害. 在右側胸腔鏡與兩側胸腔鏡及左側胸腔鏡, 有同樣好的結果.
幾條矯正板呢?
Number of bars
最初, 我們認為一條即足夠支撐, 但後來發現, 在年紀較大的病人,或凹陷範圍較廣的病例, 或馬凡氏症候群, 二條能提供便好的結果. 目前我們約有1/4是用二條矯正板.
At first we thought one support bar was sufficient, but we soon realized that two give better results in older patients or those with a diffuse (“saucer-shaped”) deformity or Marfans Syndrome. Now 26% of patients in our series receive two bars.
矯正板位移可在固定片的使用下明顯地減少發生的機會.
以前傳統手術失敗的病例, 可用微創手術治療. 我曾有74例再手術的經驗. 長期結果非常好的有88%.好的有 6%, 不良的約有6%.
We have done 74 reoperations. The immediate postoperative morbidity is increased, but the long-term results have been good to excellent in 88%, fair in 6%, and failed in 6%.
� COMPLICATIONS OF PECTUS REPAIR併發症
Bar displacement矯正板位移
使用固定片後,由8.9%降到2.3%. 後來更降到0.3%.
對材質過敏.
Nickel allergy
約有2%; 主要是在手術前對金屬或異位性過敏體質者. 可改用鈦金屬材質(台灣尚未引進)
可用低劑量類固醇治療.
植入物感染
Bar infection
發生率小於1%; 治療先用傷口引流及抗生素. 大多不需移除矯正板.
矯正板的動態
� DYNAMICS OF THE BAR
How long the bar stays in place: 要放多久才拿掉?
至少兩年; 最好三年 病人應回診並告知他們運動耐受性改善的情形.
Patients routinely report their exercise tolerance and endurance improves dramatically after the operation.
我們發現明顯地長期FVC(forceful vital capacity)及FVC1(第1秒內的FVC)肺功能改善, 但至少要手術後六個月才看得出來.
We have shown a significant long-term increase in FVC and FEV1, but this improvement takes at least 6 months to manifest.
併發症:
Early complications早期
Death: 0% 死亡率
Cardiac perforation: 0% 心傷害
Pneumothorax: 62.2% 氣胸
Requiring chest tube: 3% 需放胸管
Requiring aspiration: 0.3% 而抽吸
Hemothorax (surgical): 0.8%血胸
Pleural effusion requiring drainage: 0.3%胸腔積水且需引流
Pericarditis: 0.5% 心包膜炎
Pneumonia: 0.6%肺炎
Drug reaction: 3.9%藥物過敏
Transient Horner’s syndrome: 19.7%暫時性交感神經影響
Late complications晚期併發症
Bar displacement: 6%矯正板位移
Requiring revision: 3.2%需重置
- Before stabilizer: 8.9%在使用固定片前
- With stabilizer: 2.3%使用固定片後
- With PDS sutures: 0.1%以PDS線材
Bar infection: 0.6%感染
Requiring early removal: 需提早移除0.2%
Allergy: 2%過敏
Overcorrection: 2.9%過度矯正
Recurrence: 0.9%復發
* 以上為該院 939 位病人的統計
� HOW OUTCOMES IMPACT LIVES生活的影響
Cardiopulmonary function
Patients routinely report their exercise tolerance and endurance improves dramatically after the operation. Two-dimensional echocardiography in patients with severe pectus excavatum has shown cardiac compression causes decreased filling, which then results in decreased stroke volume and decreased cardiac output.22-24 Relieving pressure on the heart and allowing it to resume its normal configuration immediately increases stroke volume.
450
FIGURE 2 Long-term results show good to excellent outcomes
Results are for our cohort of primary surgery patients 1 year or more after bar removal, categorized by patient age at time of surgery.
The pectus deformity results in pulmonary restriction and in severe cases even paradoxical respiration. Correcting the deformity facilitates normal chest function. We have shown a significant long-term increase in forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV1), but this improvement takes at least 6 months to manifest.25,26
Fast Track
The best results occurred in the 7–12 and 13–18 age groups.
Body image
From a quality-of-life standpoint, patients with pectus excavatum have a poor body image. Their defensive camouflaging with poor posture and lifestyle restrictions—such as avoiding sports and social activities—can lead to depression. Studies have documented marked improvement in self-esteem and quality of life following minimally invasive correction.27,28
451
Long term results from our institution: 95.6% good to excellent
From 1987 through 2006, 939 patients had minimally invasive procedures at our facility, comprising 865 primary repairs and 74 reoperations. The male:female ratio was 4:1. Some 546 patients have had their bars removed, 462 of them for more than a year.
Median age of our cohort was 14.3 years (range 1–31). Echocardiography or CT scan, or both, noted cardiac compression in 84%. Mitral valve prolapse was noted in 14.5%. Preoperative resting pulmonary function testing (PFT) in 767 patients demonstrated FVC below 80% predicted value in 26%, FEV1 in 32%, and forced expiratory flow rate (FEF) of 25–75 in 41%.
We placed a single bar in 73.3% and two bars in the remainder. Most typically had epidural analgesia for 3 days. Median length of stay was 5 days.
Early complications
We reported no deaths nor cardiac perforations (TABLE 3). A small pneumothorax with spontaneous resolution is almost universal after thoracoscopy. Some 173 patients had transient Horner’s syndrome during thoracic epidural administration, but all resolved after catheter removal.
Late complications
Fifty-three patients had bar displacement, 28 of which warranted repositioning. The incidence of bar displacement dropped from 8.9% to 2.3% after stabilizers were introduced.
Six patients had infections, and two required early bar removal at 18 months. Two percent had bar allergies. Several patients had a history of metal allergy and so received titanium bars. The others were diagnosed postoperatively and treated with indomethacin or steroids. Three patients required early bar removal, two of whom received a titanium bar. Symptoms resolved in all three after bar removal.
Three percent developed a moderate overcorrection of their deformity and 0.4% developed a true carinatum deformity.
Overall results and follow-up
We evaluate patients postoperatively at 6 months for the first year, and then yearly. We classify results thus:
Excellent—total repair of the pectus excavatum and resolution of all associated symptoms.
Good—minor persistence or irregularity of the anterior chest wall with resolution of associated symptoms.
Fair—mild residual pectus excavatum without complete resolution of associated symptoms.
Poor—moderate recurrence and associated symptoms or the need for another repair or both.
Initial cosmetic and functional results were excellent in 92% of patients and good in 7.7%. One patient had a fair result, and two failed. Our long-term results in 459 patients who had their bar out for more than 1 year were excellent in 83.3%, good in 12.3%, fair in 1.7%, poor 2.7%. The best results occurred in the 7–12 and 13–18 age groups.
DN, MAK, RJO
不同於需肋骨切除及胸骨折斷術等傳統手術方式, 微創手術失血量少, 手術時間短, 且不會造成胸壁纖維化等問題. 同時病友們也可更早回復正常生活. 尤其是對兒童, 無切除組織的方式, 不會造成胸壁的纖維化. 其他如吸盤或胸骨下置入磁鐵等其他微創手術方法及凸胸(雞胸)也多以背架方式取代廣泛性切除的傳統方式了.
INDICATIONS FOR SURGERY 手術適應症
無症狀的輕微至中度凹陷病人可先追踨檢查, 有症狀的及有明顯凹陷的病人, 需檢查心肺壓迫情形.
Best Age for Operation:手術的最佳時機
最好是在青春期前, 不但矯治效果最佳, 也不容易復發.同時心肺也能有足夠的空間生長. 近年來有些報告在20-50歲手術都有很好的結果.
手術後, 如能以深呼吸及常規地有氧運動, 刺激肺部, 可減少復發率. 同時, 矯正板移除後, 也要注意挺胸姿勢的保持, 可讓復凹率降至最低.
手術的適應症為符合下列二項:
1. 凹陷指數大於3.25.
2. 心臟呈現受壓迫, 位移, 二尖瓣脫垂, 心雜音, 及傳導障礙.
3.肺功能有限制性/阻塞性障礙.
4. 以前手術失敗病例
� MINIMALLY INVASIVE TECHNIQUES
在使用了胸腔鏡後, 我們在九百個手術中沒有發生過任何心或肺的傷害. 在右側胸腔鏡與兩側胸腔鏡及左側胸腔鏡, 有同樣好的結果.
幾條矯正板呢?
Number of bars
最初, 我們認為一條即足夠支撐, 但後來發現, 在年紀較大的病人,或凹陷範圍較廣的病例, 或馬凡氏症候群, 二條能提供便好的結果. 目前我們約有1/4是用二條矯正板.
At first we thought one support bar was sufficient, but we soon realized that two give better results in older patients or those with a diffuse (“saucer-shaped”) deformity or Marfans Syndrome. Now 26% of patients in our series receive two bars.
矯正板位移可在固定片的使用下明顯地減少發生的機會.
以前傳統手術失敗的病例, 可用微創手術治療. 我曾有74例再手術的經驗. 長期結果非常好的有88%.好的有 6%, 不良的約有6%.
We have done 74 reoperations. The immediate postoperative morbidity is increased, but the long-term results have been good to excellent in 88%, fair in 6%, and failed in 6%.
� COMPLICATIONS OF PECTUS REPAIR併發症
Bar displacement矯正板位移
使用固定片後,由8.9%降到2.3%. 後來更降到0.3%.
對材質過敏.
Nickel allergy
約有2%; 主要是在手術前對金屬或異位性過敏體質者. 可改用鈦金屬材質(台灣尚未引進)
可用低劑量類固醇治療.
植入物感染
Bar infection
發生率小於1%; 治療先用傷口引流及抗生素. 大多不需移除矯正板.
矯正板的動態
� DYNAMICS OF THE BAR
How long the bar stays in place: 要放多久才拿掉?
至少兩年; 最好三年 病人應回診並告知他們運動耐受性改善的情形.
Patients routinely report their exercise tolerance and endurance improves dramatically after the operation.
我們發現明顯地長期FVC(forceful vital capacity)及FVC1(第1秒內的FVC)肺功能改善, 但至少要手術後六個月才看得出來.
We have shown a significant long-term increase in FVC and FEV1, but this improvement takes at least 6 months to manifest.
併發症:
Early complications早期
Death: 0% 死亡率
Cardiac perforation: 0% 心傷害
Pneumothorax: 62.2% 氣胸
Requiring chest tube: 3% 需放胸管
Requiring aspiration: 0.3% 而抽吸
Hemothorax (surgical): 0.8%血胸
Pleural effusion requiring drainage: 0.3%胸腔積水且需引流
Pericarditis: 0.5% 心包膜炎
Pneumonia: 0.6%肺炎
Drug reaction: 3.9%藥物過敏
Transient Horner’s syndrome: 19.7%暫時性交感神經影響
Late complications晚期併發症
Bar displacement: 6%矯正板位移
Requiring revision: 3.2%需重置
- Before stabilizer: 8.9%在使用固定片前
- With stabilizer: 2.3%使用固定片後
- With PDS sutures: 0.1%以PDS線材
Bar infection: 0.6%感染
Requiring early removal: 需提早移除0.2%
Allergy: 2%過敏
Overcorrection: 2.9%過度矯正
Recurrence: 0.9%復發
* 以上為該院 939 位病人的統計
� HOW OUTCOMES IMPACT LIVES生活的影響
Cardiopulmonary function
Patients routinely report their exercise tolerance and endurance improves dramatically after the operation. Two-dimensional echocardiography in patients with severe pectus excavatum has shown cardiac compression causes decreased filling, which then results in decreased stroke volume and decreased cardiac output.22-24 Relieving pressure on the heart and allowing it to resume its normal configuration immediately increases stroke volume.
450
FIGURE 2 Long-term results show good to excellent outcomes
Results are for our cohort of primary surgery patients 1 year or more after bar removal, categorized by patient age at time of surgery.
The pectus deformity results in pulmonary restriction and in severe cases even paradoxical respiration. Correcting the deformity facilitates normal chest function. We have shown a significant long-term increase in forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV1), but this improvement takes at least 6 months to manifest.25,26
Fast Track
The best results occurred in the 7–12 and 13–18 age groups.
Body image
From a quality-of-life standpoint, patients with pectus excavatum have a poor body image. Their defensive camouflaging with poor posture and lifestyle restrictions—such as avoiding sports and social activities—can lead to depression. Studies have documented marked improvement in self-esteem and quality of life following minimally invasive correction.27,28
451
Long term results from our institution: 95.6% good to excellent
From 1987 through 2006, 939 patients had minimally invasive procedures at our facility, comprising 865 primary repairs and 74 reoperations. The male:female ratio was 4:1. Some 546 patients have had their bars removed, 462 of them for more than a year.
Median age of our cohort was 14.3 years (range 1–31). Echocardiography or CT scan, or both, noted cardiac compression in 84%. Mitral valve prolapse was noted in 14.5%. Preoperative resting pulmonary function testing (PFT) in 767 patients demonstrated FVC below 80% predicted value in 26%, FEV1 in 32%, and forced expiratory flow rate (FEF) of 25–75 in 41%.
We placed a single bar in 73.3% and two bars in the remainder. Most typically had epidural analgesia for 3 days. Median length of stay was 5 days.
Early complications
We reported no deaths nor cardiac perforations (TABLE 3). A small pneumothorax with spontaneous resolution is almost universal after thoracoscopy. Some 173 patients had transient Horner’s syndrome during thoracic epidural administration, but all resolved after catheter removal.
Late complications
Fifty-three patients had bar displacement, 28 of which warranted repositioning. The incidence of bar displacement dropped from 8.9% to 2.3% after stabilizers were introduced.
Six patients had infections, and two required early bar removal at 18 months. Two percent had bar allergies. Several patients had a history of metal allergy and so received titanium bars. The others were diagnosed postoperatively and treated with indomethacin or steroids. Three patients required early bar removal, two of whom received a titanium bar. Symptoms resolved in all three after bar removal.
Three percent developed a moderate overcorrection of their deformity and 0.4% developed a true carinatum deformity.
Overall results and follow-up
We evaluate patients postoperatively at 6 months for the first year, and then yearly. We classify results thus:
Excellent—total repair of the pectus excavatum and resolution of all associated symptoms.
Good—minor persistence or irregularity of the anterior chest wall with resolution of associated symptoms.
Fair—mild residual pectus excavatum without complete resolution of associated symptoms.
Poor—moderate recurrence and associated symptoms or the need for another repair or both.
Initial cosmetic and functional results were excellent in 92% of patients and good in 7.7%. One patient had a fair result, and two failed. Our long-term results in 459 patients who had their bar out for more than 1 year were excellent in 83.3%, good in 12.3%, fair in 1.7%, poor 2.7%. The best results occurred in the 7–12 and 13–18 age groups.
DN, MAK, RJO
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