Pectus Excavatum – Indications for Surgery, Modern Treatment Methods – Literature Review
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Date
2022
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Rīgas Stradiņa universitāte
Rīga Stradiņš University
Rīga Stradiņš University
Abstract
Pectus excavatum (PE) ir iedzimta krūškurvja sienas deformācija, kad krūšu kauls un blakus esošie piekrastes skrimšļi ir nospiesti aizmugurē. Parasti PE ķirurģiska ārstēšana ir indicēta pacientiem ar smagu PE, kā arī simptomātiskiem pacientiem.
Nuss procedūra (“minimāli invazīva procedūra”) ir pašreizējais PE rekonstrukcijas standarts. Izmantojot nelielus divpusējus ādas iegriezumus, Nuss stienis tiek ievietots krūškurvja dobumā, lai paceltu krūšu kauli un rekonstruētu krūškurvi. Priekšrocības ietver nelielus iegriezumus sānu malās ar labu kosmētisko rezultātu un zemu brūču infekciju risku, salīdzinoši ātru operāciju un ātru atveseļošanos. Starp trūkumiem var minēt nepieciešamību pēc otras operācijas stieņa noņemšanai, stipras pēcoperācijas sāpes, kā arī iespējamo augšanas ierobežojumu smagos gadījumos, kad bija jāievieto vairāki stieņi.
Raviča procedūru ("atklātā procedūra") galvenokārt izmanto pieaugušiem pacientiem vai pacientiem ar asimetrisku krūškurvja zonu. Šīs procedūras laikā tiek veikts slīps ādas iegriezums, lai atklātu krūšu kaula un piekrastes skrimšļus. Deformētie skrimšļi un xiphoid process tiek izgriezti un tiek veikta krūšu kaula priekšējās garozas daļas šķērseniskā ķīļa osteotomija, lai nodrošinātu krūšu kaula sānu malu veidošanu. Piekrastes skrimšļi un xiphoid process tiek atkārtoti piestiprināti, lai izlīdzinātu krūšu kurvja priekšējo sienu.
Šīs procedūras galvenā priekšrocība ir plašais pacientu spektrs, jo šo procedūru var veikt pieaugušiem pacientiem, smagām un asimetriskām deformācijām. Galvenais trūkums ir lielais ādas griezums ar diezgan neestētisku rezultātu, kā arī nepieciešamība veikt skrimšļu rezekciju un augšanas centra rezekcijas risks.
Ķirurģiskā PE remonta vispārējās komplikācijas ir zāļu reakcijas, pēcoperācijas sāpes, brūču infekcijas, pneimotoraksa vai hemotoraksa veidošanās, pneimonija, pārmērīga vai nepietiekama korekcija, kā arī PE atkārtošanās.
Komplikācijas, kas raksturīgas Nuss procedūrai, ietver stieņa migrāciju un pārvietošanos, sirds bojājumus un ķirurģiskas komplikācijas stieņa noņemšanas laikā. Raviča procedūras laikā vairums specifisko komplikāciju ir saistītas ar skrimšļa noņemšanu. Var attīstīties sekundāra krūšu kurvja distrofija, malūnija ar krūškurvja sienas nestabilitāti vai osteonekroze.
Brūču infekcijas novērš profilaktiska antibakteriāla ārstēšana, pirmsoperācijas ādas dezinfekcija un stingra sterila ķirurģiska tehnika. Pēcoperācijas sāpēm nepieciešama daudznozaru pieeja. Lai veiksmīgi kontrolētu sāpes, ir izmantota izglītošana un rehabilitācija pēc operācijas, adekvāta farmakoloģiskā sāpju kontrole ar NPL, opioīdiem, sedatīviem līdzekļiem un muskuļu relaksantiem, kā arī dažos gadījumos reģionālā nervu blokāde, epidurālā anestēzija vai krioablācija. Lai novērstu stieņu nobīdes, ir ieviestas fiksācijas sistēmas. Intraoperatīvie sirds bojājumi tiek novērsti, izmantojot pirmsoperācijas un intraoperatīvo attēlveidošanu.
Pectus excavatum (PE) is a congenital chest wall deformation, where sternum and the adjacent costal cartilages are depressed posteriorly. Generally, surgical treatment of PE is indicated in patient with severe PE as well as in symptomatic patients. The Nuss Procedure, (“minimally invasive procedure”) is the current standard of PE reconstruction. Via small bilateral skin incisions, the Nuss bar is inserted into the chest cavity to elevate the sternum and reconstruct the thorax. The advantages include the small incisions on lateral sides with good cosmetic result and a low risk for wound infections, the relatively quick surgery and fast recovery. Disadvantages include the need for a second surgery to remove the bar, the severe post-operative pain as well as the possible growth restriction in severe cases, when several bars had to be implanted. The Ravitch Procedure, ("open procedure") is mainly used for adult patients or patient with an asymmetric thorax. During this procedure, an oblique skin incision is done to expose the sternum an costal cartilages. The deformed cartilages and the xiphoid process are resected and a transverse wedge osteotomy of the anterior cortical part of the sternum is done to enable the moulding of the lateral margins of the sternum. The costal cartilages and the xiphoid process are reattached to realign the anterior thoracic wall. The major advantage for this procedure is the broad patient spectrum as this procedure can be done in adult patients, severe and asymmetric deformities. The main disadvantage is the large skin incision with a rather unaesthetic result as well as the need to resect cartilages and the risk of growth center resection. General complications of the surgical PE repair include drug reactions, postoperative pain, wound infections, pneumo- or hemothorax formation, pneumonia, over- or undercorrection, as well as the recurrence of PE. Complications specific to Nuss Procedure include bar migration and displacement, cardiac injury and surgical complication during bar removal. During Ravitch Procedure, most specific complications are related to the cartilage removal. Secondary thoracic dystrophy, malunion with resulting chest wall instability or osteonecrosis can develop. Wound infections are prevented by prophylactic antibacterial treatment, preoperative skin disinfection and strict sterile surgical technique. Post-surgical pain requires a multidisciplinary approach. Education and rehabilitation after surgery, adequate pharmacological pain control with NSAIDs, Opioids, sedatives and muscle relaxants, and in some cases regional nerve blocks, epidural anesthesia or cryoablation have been used to successfully control the pain. To prevent bar displacements, fixation systems have been implemented. Intra-operative cardiac injuries are prevented by the use of preoperative and intraoperative imaging.
Pectus excavatum (PE) is a congenital chest wall deformation, where sternum and the adjacent costal cartilages are depressed posteriorly. Generally, surgical treatment of PE is indicated in patient with severe PE as well as in symptomatic patients. The Nuss Procedure, (“minimally invasive procedure”) is the current standard of PE reconstruction. Via small bilateral skin incisions, the Nuss bar is inserted into the chest cavity to elevate the sternum and reconstruct the thorax. The advantages include the small incisions on lateral sides with good cosmetic result and a low risk for wound infections, the relatively quick surgery and fast recovery. Disadvantages include the need for a second surgery to remove the bar, the severe post-operative pain as well as the possible growth restriction in severe cases, when several bars had to be implanted. The Ravitch Procedure, ("open procedure") is mainly used for adult patients or patient with an asymmetric thorax. During this procedure, an oblique skin incision is done to expose the sternum an costal cartilages. The deformed cartilages and the xiphoid process are resected and a transverse wedge osteotomy of the anterior cortical part of the sternum is done to enable the moulding of the lateral margins of the sternum. The costal cartilages and the xiphoid process are reattached to realign the anterior thoracic wall. The major advantage for this procedure is the broad patient spectrum as this procedure can be done in adult patients, severe and asymmetric deformities. The main disadvantage is the large skin incision with a rather unaesthetic result as well as the need to resect cartilages and the risk of growth center resection. General complications of the surgical PE repair include drug reactions, postoperative pain, wound infections, pneumo- or hemothorax formation, pneumonia, over- or undercorrection, as well as the recurrence of PE. Complications specific to Nuss Procedure include bar migration and displacement, cardiac injury and surgical complication during bar removal. During Ravitch Procedure, most specific complications are related to the cartilage removal. Secondary thoracic dystrophy, malunion with resulting chest wall instability or osteonecrosis can develop. Wound infections are prevented by prophylactic antibacterial treatment, preoperative skin disinfection and strict sterile surgical technique. Post-surgical pain requires a multidisciplinary approach. Education and rehabilitation after surgery, adequate pharmacological pain control with NSAIDs, Opioids, sedatives and muscle relaxants, and in some cases regional nerve blocks, epidural anesthesia or cryoablation have been used to successfully control the pain. To prevent bar displacements, fixation systems have been implemented. Intra-operative cardiac injuries are prevented by the use of preoperative and intraoperative imaging.
Description
Medicīna
Medicine
Veselības aprūpe
Health Care
Medicine
Veselības aprūpe
Health Care
Keywords
Pectus Excavatum, Nuss procedūra, Ravitch procedūra, stieņa pārvietošana, brūču infekcija, profilakse, riska samazināšana, Hallera indekss, korekcijas indekss, minimāli invazīva PE remonta pieeja, atklāta procedūra Pectus Excavatum remontam, Pectus Excavatum, Nuss Procedure, Ravitch Procedure, Bar displacement, Wound infection, Prevention, Risk Reduction, Haller index, Correction index, Minimally invasive approach of PE Repair, Open Procedure for Pectus Excavatum repair