Swanson Jordan W, Colombani Paul M
Division of Pediatric Surgery, The Johns Hopkins School of Medicine, Baltimore, MD 21205, USA.
J Pediatr Surg. 2008 Aug;43(8):1468-73. doi: 10.1016/j.jpedsurg.2007.11.019.
The Ravitch and minimally invasive Nuss procedures have brought widespread relief to children with pectus excavatum, chest wall deformities, over the last half century. Generally accepted long-term complications of pectus excavatum repair are typically limited to recurrence of the excavatum deformity or persistent pain. This study examines the authors' experience with patients who develop a subsequent carinatum deformity within 1 year of pectus excavatum repair.
The authors retrospectively assessed the charts of all patients diagnosed as having a carinatum deformity subsequent to treatment for pectus excavatum at a tertiary urban hospital. We noted age at original correction of pectus excavatum, time from original correction to diagnosis of carinatum deformity, age at correction of carinatum deformity, complaints before correction, methods of repair, postoperative complications, and we reviewed relevant radiography.
Three patients who underwent pectus excavatum repair between January 2000 and August 2007 developed a subsequent carinatum deformity. Two patients initially underwent minimally invasive Nuss correction of pectus excavatum; 1 patient underwent the Ravitch procedure. Within 1 year of original correction and despite intraoperative achievement of neutral sternal position, a protruding anterior chest deformity resembling de novo pectus carinatum emerged in each patient; we term this condition reactive pectus carinatum. The mean age of patients undergoing initial pectus excavatum repair was 13 years (range, 11-16 years). The pathophysiology of this reactive lesion is not well understood but is thought to originate from reactive fibroblastic stimulation as a result of sternal manipulation and bar placement. Patients who underwent Nuss correction initially were managed with early bar removal. Two of the patients eventually required surgical resection of the carinatum deformity at a time interval of 3 to 6 years after initial excavatum repair. In one patient, the carinatum deformity resolved spontaneously. Neutral chest position and absence of dyspenic symptoms were achieved in all patients.
Reactive pectus carinatum is functionally encumbering and a poor cosmetic complication of either the Ravitch or minimally invasive Nuss procedures. Our experience with reactive pectus carinatum introduces the importance of postoperative vigilance even in patients without underlying fibroelastic disease. Examination of the chest with attention to the possibility of an emerging carinatum deformity, particularly in the first 6 postoperative months, is paramount. A telephone call to the patient at 3 months may be a useful adjunct to clinic visits. An optimal long-term result may be achieved through a combination of early Nuss bar removal or postpubertal pectus carinatum repair.
在过去的半个世纪里，Ravitch手术和微创Nuss手术为患有漏斗胸、胸壁畸形的儿童带来了广泛的缓解。一般认为漏斗胸修复的长期并发症通常仅限于漏斗胸畸形复发或持续疼痛。本研究探讨了作者对在漏斗胸修复术后1年内出现鸡胸畸形患者的治疗经验。
作者回顾性评估了一家城市三级医院中所有经诊断在漏斗胸治疗后出现鸡胸畸形患者的病历。我们记录了初次漏斗胸矫正时的年龄、从初次矫正到诊断鸡胸畸形的时间、鸡胸畸形矫正时的年龄、矫正前的症状、修复方法、术后并发症，并查阅了相关影像学资料。
2000年1月至2007年8月期间接受漏斗胸修复手术的3例患者随后出现了鸡胸畸形。2例患者最初接受了漏斗胸的微创Nuss矫正；1例患者接受了Ravitch手术。在初次矫正后的1年内，尽管术中实现了胸骨中立位，但每名患者均出现了类似新发鸡胸的前胸突出畸形；我们将这种情况称为反应性鸡胸。初次接受漏斗胸修复手术的患者平均年龄为13岁（范围11 - 16岁）。这种反应性病变的病理生理学尚不完全清楚，但被认为源于胸骨操作和放置钢板导致的反应性成纤维细胞刺激。最初接受Nuss矫正的患者通过早期取出钢板进行处理。其中2例患者最终在初次漏斗胸修复术后3至6年需要手术切除鸡胸畸形。1例患者的鸡胸畸形自行缓解。所有患者均实现了胸部中立位且无呼吸困难症状。
反应性鸡胸在功能上有阻碍，是Ravitch手术或微创Nuss手术的一种不良美容并发症。我们对反应性鸡胸的治疗经验表明，即使在没有潜在纤维弹性疾病的患者中，术后警惕也很重要。检查胸部时要注意出现鸡胸畸形的可能性，尤其是在术后的前6个月，这至关重要。术后3个月给患者打电话可能是门诊就诊的有益补充。通过早期取出Nuss钢板或青春期后修复鸡胸畸形相结合，可能会获得最佳的长期效果。
