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1 =Abstract= Nuss 술식에기초한누두흉의최소침습수술 : 수술수기의개발및 322 예의조기성적 Minimally Invasive Repair of Pectus Excavatum Based on the Nuss Principle: An Evolution of Techniques and Early Results on 322 Patients Background: The Nuss procedure is a recently developed technique for minimally invasive repair of pectus excavatum using a metal bar. Although its technical simplicity and cosmetic advantages are remarkable, applications have been limited to children with standard pectus excavatum. We report a single center experience of the technique that has been evolving in order to correct asymmetric pectus configurations and adult patients. Material and Method: Between August 1999 and June 2002, 322 consecutive patients underwent repair by the Nuss technique and its modifications. Among them, 71 (22%) were adults. For the precise correction, morphology of the pectus was classified as symmetric and asymmetric types. Asymmetric type was subdivided into eccentric and unbalanced types. In repair, differently shaped bars were applied to individual types of pectus to achieve symmetric correction. Result: Symmetric type was 57.5% (185/322) and asymmetric type was 42.5% (137/322). Eccentric, unbalanced, and combined types were 71, 47 and 19, respectively. Major modifications were bar shaping and fixation. In asymmetric group, different shapes of asymmetric bars were applied (n=125, 38.8%). For adult patients, double bar or compound bar technique was used (n=51, 15.8%). To prevent bar rotation, multipoint wire fixations to ribs were used. Major postoperative complications were pneumothorax (n=24, 7.5%) and bar displacement (n=11, 3.4%). 42 patients had bar removal 2 years after the initial procedure. Conclusion: The Nuss procedure is safe and effective. Modifications of the techniques in accordance with precise morphological classification enabled the correction of all variety of pectus excavatum including asymmetric types and adult patients. (Korean J Thorac Cardiovasc Surg 2003;36: ) Key words: 1. Funnel chest 2. Surgery method Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Chunan Hospital , ( ) 23-20, (Tel) , (Fax) , hyjpark@sch.ac.kr.

2 H * Metalbar H * H * H * Fig. 1. Principal Technique of the Nuss Procedure: Schematic drawings and CT scans. H, H; hinge points. 서론 1997 Donald Nuss 1) ,.,.. 대상및방법 ( ) (77.9%), (22.1%) Ravitch Wada 10 (post-ravitch 9, post-wada 1 ). Poland 2 Nuss Fig. 2. (symmetry) (asymmetry) (Fig. 2).,.

IA IB E point IIA1 IIA2 IIA3 IIB IIC Fig. 2.

flat 12 1: focal 33 2: broad flat 10 3: long

point; protruded point of chest wall (Type 1)

unbalanced type, type 2B), (combined type,

3 IA IB E point IIA1 IIA2 IIA3 IIB IIC Fig. 2. Morphological classification of pectus excavatum (n=322). Type I: Symmetric type % Type II: Asymmetric type % A: classical 173 A: eccentric 71 B: broad flat 12 1: focal 33 2: broad flat 10 3: long canal 28 B: unbalanced 47 C: combined 19 E point; protruded point of chest wall (Type 1) (standard type, type 1A) (broad-flat type, type 1B) (subtype) (Fig. 2). (Type 2) (, eccentric type, type 2A) (, unbalanced type, type 2B), (combined type, type 2C)., (, unbalanced type, type 2B) (Fig. 2). (focal type, type 2A1, 2B1), (broad-flat type, 2A2, 2B2). (Grand Canyon type, type 2A3) (Fig. 2). CT scan

4 H C H H C H 1 2 P C P E 3 a b b a a = a b = b 4 n=125(38.8%) n=40(12.4%) H H H H 5 6 D D D D n=31(9.6%) Fig. 3. Bar shaping. 1. Classical 2. Bridge 3. Asymmetric 4. Seagull 5. Hump 6. Compound C, center of the bar; D, diameter of the circle; E, elevated point of sternum; H, hinge points; P, deepest point of pectus.., CT Index (CTI= transverse diameter/vertical diameter) 2). Fig. 1 Table 1. (hinge points, H point) (Fig. 1)., (H point), (midaxillary lines) 1 2 cm H point right angle clamp. pectus clamp H point H' point. pectus clamp (guider) Table 1. Operative procedures 1. Supine position with arms abduction 2. Marking the center of the sternum (C), center of the depression (P), hinge points (H) and incision sites 3. Measuring the size of the chest for selection of bar 4. Marking on the bar and bending 5. Incision on the marked sites at both mid-axilary lines 6. Subcutaneous tunnels to the bar entering intercostal spaces (H points) 7. Penetrating the intercostal space and passing clamp beneath the sternum to the other H point 8. Passing a guider (32 Fr. chest tube or 2 umbilical tapes) with the clamp 9. Passing the bent bar by pulling the guider 10. Bar in position with the convexity facing posteriorly 11. Turning over the bar to make convexity face anteriorly (elevating depressed sternum): KEY PROCEDURE 12. Fixation of the bar to ribs 13. Intercostal nerve block and closure 14. Chest x-ray in the OR upon completion of the procedure

5 32 Fr. (chest tube) clamp. (Walter Lorenz Surgical, 1520 Tradeport Dr., Jacksonville, FL 32218). (convexity). 180 H point. H point (Table 1). : (type 1A) (C). Nuss (Fig. 3-1), (H point) (bridge shape) (over-correction) (Fig. 3-2).. (eccentric type, type 2A) Fig (P point). H point (Fig. 3-3). (unbalanced type, type 2B) (E point) (Fig. 3-4). (compound bar shape). 2 hump shape (Fig. 3-5), hinge point (D D') (Fig. 3-6). :. : 2 2. : 2. : 10. (stabilizer) hinge point 5 (5 point fixation). Ravitch Wada (central fixation). 2.. C-arm fluoroscopy. 결과 (57.5%). 173 (93.5%) (standard type, type 1A), 12 (6.5%) (broad-flat type, type 1B). 137 (42.5%). (, eccentric type, type 2A) 71 (52.6%).. (Grand Canyon type, type 2A3) 24 (17.5%) (Fig. 2). 47 (34.3%) (,

6 unbalanced type, type 2B) (Fig. 2). 19 (13.9%) (combined type, type 2C) (Fig. 2). CTI 6.3 ( ) CTI 2.7 ( ) CTI 4.3 ( ). 197 (61.2%), 125 (38.8%). seagull 40 (12.4%). 143 (44.4%) (oblique bar placement). 42 (13.0%) (parallel bar technique), 20 (6.2%) (double bar technique) (9.6%) (compound bar). 143 (44.4%) (stabilizer), (5 point fixation) 65. Ravitch Wada 10 (3.1%) (central fixation). 61 (18.9%). ( 30 ) 49 (15.2%) 24 (7.5%), seroma 10 (3.1%) 8 (2.5%),,,. ( 31 ) 12 (3.7%), 5, 3 (Table 2). 6.0 ( 2 22 ), 5.3 ( 1 22 ), 6.9 ( 4 16 ). 14 (4.3%). (11, 3.4%). (major displacement) 4, (minor displacement) 7. 2 Table 2. Complications 1. Pneumothorax 24 (7.5%) Spontaneous resolution 11 Needle aspiration 4 Chest tube 1 PCD 8 2. Bar displacement 11 (3.4%) Major (flipped bar) 4 Minor 7 ) 3. Wound seroma 10 (3.1%) 4. Pleural effusion 8 )(2.5%) 5. Pericardial Effusion (pericarditis) 8 )(2.5%) 6. Pneumonia 3 (0.9%) 7. Hemothorax (0.9%) 8. Cardiac perforation 1 (0.3%) Total 61 (18.9%) Early 49 (15.2%) Late ( 30 days) 12 (3.7%) Tension Late complication; PCD, percutaneous catheter drainage.. 1 Marfan (13.7%). 42 2, 2. 1 Poland, 10, 1,. 42. 고 찰

7 Ravitch-type 3) (musculoskeletal flap) (sternal turnover) 4) ) (multi-institutional survey) ) ). (learning curve) 7,10,11).. Nuss.. ( ) (center of depression). (hinge points)., (horizontal bar placement) (oblique bar placement).. Fig ,... 6,12) ( ) 5). Nuss.. Nuss,. (eccentric type, type 2A).. (P point). Fig (unbalanced type).,. Fig. 3-4 (sea-gull shape), (hinge point) (crest compression technique).

8 ... (Grand Canyon type). Nuss 1) (double bar technique). 2. (hinge point) (stabilizer).. (compound bar technique). (compound bar shape). 1A (bridge shape).. (hump shape) (D') (D)..,. (Double Bar).. Nuss. (standard type, type 1A)... Nuss, 5,7,10,13).. (stabilizer).. 10., (multi-point fixation)...

9 (flipped bar), (lateral sliding), hinge point (hinge point breaking) (major displacement) (minor displacement). hinge point. (sliding). (depressed side). hinge point. hinge point... Hebra 13) Croitoru 14), (multi-point fixation). 5) 9.2% 4.3% 19% 6,7,10)., 3.4%, (major displacement, flipped bar) 4 (1.2%). Ravitch Wada..... (central fixation).,. x-ray. 2 3 (pulse oxymetry), x-ray. x-ray 1, 2 3.,. hemovac catheter underwater-seal.,....,.., PCD (percutaneous catheter drainage)

10 pectus clamp. clamp.. clamp % Marcaine 2 3 (PCA, Patient Controlled Analgesia) (Fentanyl 0.7 mcg/kg/min) , 16, 1, 결론.. Nuss., Nuss.,. Nuss..,,. 참고문헌 1. Nuss D, Kelly RE, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33: Haller JA Jr, Kramer SS, Lietman SA. Use of CT scans in selection of patients for pectus excavatum surgery: A preliminary report. J Pediatr Surg 1987;22: Ravitch MM. The operative treatment of pectus excavatum. Ann Surg 1949;129: Wada J, Ikeda K, Ishida T, Hasegawa T. Result of 271 funnel chest operations. Ann Thorac Surg 1970;10: Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases. J Pediatr Surg 2000;35: Miller KA, Woods RK, Sharp RJ, et al. Minimally invasive repair of pectus excavatum: a single institution's experience. Surgery 2001;130: Molik KA, Engum SA, Rescorla FJ, West KW, Scherer LR, Grosfeld JL. Pectus excavatum repair: experience with standard and minimal invasive techniques. J Pediatr Surg 2001; 36: Wu PC, Knauer EM, McGowan GE, Hight DW. Repair of pectus excavatum deformities in children: a new perspective of treatment using minimal access surgical technique. Arch Surg 2001;136: ,,,. 2001;34: Engum S, Rescorla F, West K, Rouse T, Scherer LR, Grosfeld J. Is the grass greener? Early results of the Nuss procedure. J Pediatr Surg 2000;35: Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: Case reports. J Pediatr Surg 2001;36: Jacobs JP, Quintessenza JA, Morell VO, Botero LM, van Gelder HM, Tshervenkov CI. Minimally invasive endoscopic repair of pectus excavatum. Eur J Cardiothorac Surg 2002; 21: Hebra A, Gauderer MW, Tagge EP, Adamson WT, Othersen HB Jr. A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum. J Pediatr Surg 2001;36: Croitoru DP, Kelly RE Jr, Goretsky MJ, Lawson ML, Swoveland B, Nuss D. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg 2002;37:

11 = 국문초록 = 배경 :.... 대상및방법 : (22%).... 결과 : 57.5% (185/322) 42.5% (137/322)., 71, 47, (38.8%). 51 (15.8%).. 24 (7.5%), 11 (3.4%) 결론 :.,. 중심단어

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