بررسي انديكاسيونها و نتايج حاصل از جراحي در بيماران با بدشكلي هاي قفسه سينه در استان گيلان

Survey of Indication and Results of Surgery in Patients with Chest Wall Deformity in Guilan Province

زﻣﯿﻨﻪ و ﻫﺪف: در ﺟﺪار ﻗﻔﺴﻪ ﺳﯿﻨﻪ اﻧﻮاﻋﯽ از ﻧﺎﻫﻨﺠﺎري ﻫﺎي ﻣﺎدرزادي وﺟﻮد دارد ﮐﻪ ﻋﻤﺪﺗﺎ ًﺷﺎﻣﻞ ﻧﺎﻫﻨﺠﺎري ﻫﺎي ﭘﮑﺘﻮس و ﻧﻘﺺ ﻫﺎي اﺳﺘﺨﻮان ﺟﻨﺎغ ﺳﯿﻨﻪ ﻣﯽ ﺑﺎﺷﺪ. اﯾﻦ ﻧﺎﻫﻨﺠﺎري ﻫﺎ ﺑﯿﺸﺘﺮ اﺛﺮات ﻧﺎﻣﻄﻠﻮب رواﻧﯽ و ﻓﯿﺰﯾﻮﻟﻮژﯾﮏ دارﻧﺪ. ﺗﺮﻣﯿﻢ اﯾﻦ ﻧﺎﻫﻨﺠﺎري ﻫﺎ ﻣﻮرﺗﺎﻟﯿﺘﯽ و ﻣﻮرﺑﯿﺪﯾﺘﯽ ﻧﺎﭼﯿﺰي دارﻧﺪ و ﺑﺎ اﺻﻼح آن ﻣﺸﮑﻼت رواﻧﯽ و ﻓﯿﺰﯾﻮﻟﻮژﯾﮏ ﻣﺒﺘﻼﯾﺎن ﺣﻞ ﻣﯽ ﺷﻮد، ﻣﻄﺎﻟﻌﻪ ﺣﺎﺿﺮ ﺑﻪ ﻣﻨﻈﻮر ﺑﺮرﺳﯽ اﻧﺪﯾﮑﺎﺳﯿﻮنﻫﺎ وﻧﺘﺎﯾﺞ ﺟﺮاﺣﯽ در ﺑﯿﻤﺎران ﺑﺎ ﺑﺪﺷﮑﻠﯽﻫﺎي ﻗﻔﺴﻪ ﺳﯿﻨﻪ در اﺳﺘﺎن ﮔﯿﻼن اﻧﺠﺎم ﮔﺮﻓﺘﻪ اﺳﺖ. ﻣﻮاد و روش ﻫﺎ: در اﯾﻦ ﻣﻄﺎﻟﻌﻪ ﮔﺬﺷﺘﻪﻧﮕﺮ 52 ﺑﯿﻤﺎر )38 ﻣﺮد و 14 زن( ﺑﺎ ﺑﺪﺷﮑﻠﯽﻫﺎي ﻗﻔﺴﻪ ﺳﯿﻨﻪ ﮐﻪ ﺗﺤﺖ ﻋﻤﻞ ﺟﺮاﺣﯽ ﺗﺮﻣﯿﻤﯽ در دو ﺑﯿﻤﺎرﺳﺘﺎن رازي و آرﯾﺎ ﻣﻮرد ﻣﻄﺎﻟﻌﻪ ﻗﺮار ﮔﺮﻓﺘﻨﺪ. ﺗﻤﺎم ﺑﯿﻤﺎران ﺑﺠﺰ اﺳﺘﺮﻧﺎل ﮐﻠﻔﺖ ﺗﺤﺖ اﻗﺪام ﺗﺸﺨﯿﺼﯽ ﺳﯽﺗﯽ اﺳﮑﻦ، ﻋﮑﺲ ﻗﻔﺴﻪ ﺳﯿﻨﻪ ﻗﺮار ﮔﺮﻓﺘﻨﺪ. ﻋﻤﻞ ﺟﺮاﺣﯽ راوﯾﭻ ﺑﺮاي ﺑﯿﻤﺎران ﭘﮑﺘﻮس اﮐﺴﮑﺎواﺗﻮم و ﭘﮑﺘﻮس ﮐﺎرﯾﻨﺎﺗﻮم ﺻﻮرت ﮔﺮﻓﺖ و رزﮐﺸﻦ دﻧﺪه ﻫﺎي ﺑﺮﺟﺴﺘﻪ در ﺑﺪﺷﮑﻠﯽ ﻗﻔﺴﻪ ﺳﯿﻨﻪ اﻧﺠﺎم ﺷﺪ و در اﯾﻦ ﺷﺮاﯾﻂ، ﻧﻘﺺ اﯾﺠﺎد ﺷﺪه ﺑﺎﻋﻀﻠﻪ ﭘﮑﺘﻮراﻟﯿﺲ ﻣﺎژور و ﻣﺶ ﺗﺮﻣﯿﻢ ﺷﺪﻧﺪ و ﮐﻨﺪروﺗﻮﻣﯽ ﺑﺮاي ﺑﯿﻤﺎران اﺳﺘﺮﻧﺎل ﮐﻠﻔﺖ اﻧﺠﺎم ﺷﺪ. ﺑﺮاي ﺗﺠﺰﯾﻪ و ﺗﺤﻠﯿﻞ دادهﻫﺎي ﺗﻮﺻﯿﻔﯽ از آزﻣﻮنﻫﺎي آﻣﺎري ﻣﯿﺎﻧﮕﯿﻦ اﻧﺤﺮاف اﺳﺘﺎﻧﺪارد درﺻﺪ و ﻓﺮاواﻧﯽ اﺳﺘﻔﺎده ﺷﺪ. ﯾﺎﻓﺘﻪ ﻫﺎ: ﻣﯿﺎﻧﮕﯿﻦ ﺳﻨﯽ ﺑﯿﻤﺎران 14/81±8/5 ﺳﺎل ﺑﻮد ﮐﻪ ﮔﺴﺘﺮه 3 ﺗﺎ 30 ﺳﺎل را در ﺑﺮﻣﯽﮔﺮﻓﺖ. ﺷﺎﯾﻊ ﺗﺮﯾﻦ ﺷﮑﺎﯾﺖ اوﻟﯿﻪ در ﺑﯿﻤﺎران ﻣﺮاﺟﻌﻪ ﮐﻨﻨﺪه ﺑﺪ ﺷﮑﻠﯽ در 52 ﺑﯿﻤﺎر )100%( دﯾﺪه ﺷﺪ. از 52 ﺑﯿﻤﺎر32 ﺑﯿﻤﺎر ﭘﮑﺘﻮس اﮐﺴﮑﺎواﺗﻮم )61/53%( و 10 ﺑﯿﻤﺎر ﭘﮑﺘﻮس ﮐﺎرﯾﻨﺎﺗﻮم )19/23%(، 7 ﺑﯿﻤﺎر )13/4%( ﺑﺪﺷﮑﻠﯽ دﻧﺪه و 3 ﺑﯿﻤﺎر )5/7%( اﺳﺘﺮﻧﺎل ﮐﻠﻔﺖ داﺷﺘﻨﺪ. ﺷﺪت ﭘﮑﺘﻮس اﮐﺴﮑﺎواﺗﻮم از 3 ﺗﺎ 5 ﺳﺎﻧﺘﯿﻤﺘﺮ ﻣﺘﻐﯿﺮ ﺑﻮد. در ﺑﯿﻤﺎران ﺑﺎ ﺳﻦ ﺑﺎﻻﺗﺮ از ﭘﺎﻧﺰده ﺳﺎل ﺗﻌﺪاد ﭘﯿﻦ ﺑﮑﺎر رﻓﺘﻪ ﺑﺮاي ﻓﯿﮑﺲ ﮐﺮدن اﺳﺘﺮﻧﻮم دو ﻋﺪد ﺑﻮد. ﻣﺶ ﭘﺮوﻟﻦ ﺑﺮاي ﺛﺎﺑﺖ ﮐﺮدن اﺳﺘﺮﻧﻮم در ﭼﻬﺎر ﺑﯿﻤﺎر ﺑﮑﺎر ﺑﺮده ﺷﺪ ﺑﯿﺸﺘﺮ ﺑﯿﻤﺎران ﺑﺪون ﻋﺎرﺿﻪ ﻣﻬﻢ ﺗﺮﻣﯿﻢ ﺷﺪﻧﺪ و ﻋﻮارض ﻋﻤﻞ ﺷﺎﻣﻞ 8 ﻣﻮرد ﭘﻨﻮﻣﻮﺗﻮراﮐﺲ )4 ،(%15/38 ﻣﻮرد ﭘﻨﻮﻣﻮﻧﯽ )3 ،(%7/69 ﻣﻮرد آﺗﻠﮑﺘﺎزي )5/76%( و 2 ﻣﻮرد ﻋﻔﻮﻧﺖ ﻧﺎﺷﯽ از ﻣﯿﻠﻪ )3/84%( ﺑﻮد. ﻋﻮارض ﻋﻤﻞ ﺟﺮاﺣﯽ در ﺑﯿﻤﺎران ﺑﺎ ﺳﻦ ﺑﺎﻻﺗﺮ از ﭘﺎﻧﺰده ﺳﺎل ﺑﯿﺸﺘﺮ ﺑﻮده اﺳﺖ. ﻫﯿﭻ ﻣﻮرد ﻋﻮدي رؤﯾﺖ ﻧﺸﺪ. ﺷﺪت درد در ﺑﯿﻤﺎران 6 از10 ﺑﻮد )42/3%(. ﻧﻤﺮه درد در ﺑﯿﻤﺎران ﺑﺎ ﺳﻦ ﺑﺎﻻﺗﺮ از ﭘﺎﻧﺰده ﺳﺎل ﺑﻪ ﻃﻮر ﭼﺸﻢﮔﯿﺮي ﺑﺎﻻﺗﺮ ﺑﻮد. ﻃﻮل ﻣﺪت ﺑﺴﺘﺮي از 3 ﺗﺎ 7 روز ﻣﺘﻐﯿﺮ ﺑﻮد. ﻃﻮل ﻣﺪت ﺑﺴﺘﺮي ﺑﯿﻤﺎران ﺑﺎ ﺳﻦ ﺑﺎﻻ ﺗﺮ از ﭘﺎﻧﺰده ﺳﺎل ﺑﻪ ﻃﻮر ﭼﺸﻢﮔﯿﺮي ﺑﯿﺸﺘﺮ ﺑﻮد. ﺑﯿﻤﺎران ﺗﺤﺖ ﭘﯿﮕﯿﺮي 2 ﺗﺎ 6 ﺳﺎﻟﻪ ﻗﺮار ﮔﺮﻓﺘﻨﺪ. 15ﻣﻮرد )28/84%( ﺑﯿﻤﺎران ﻣﯿﺰان رﺿﺎﯾﺘﻤﻨﺪي ﻋﺎﻟﯽ دﺷﺘﻨﺪ و 35 ﻣﻮرد )67/30%( رﺿﺎﯾﺘﻤﻨﺪي ﺧﻮب و 2 ﻣﻮرد )3/84%( رﺿﺎﯾﺖ ﻧﺪاﺷﺘﻨﺪ. ﻧﺘﯿﺠﻪ ﮔﯿـﺮي: ﭘﮑﺘﻮس اﮐﺴﮑﺎواﺗﻮم و ﭘﮑﺘﻮس ﮐﺎرﯾﻨﺎﺗﻮم و اﺳﺘﺮﻧﺎل ﮐﻠﻔﺖ ﺑﻬﺘﺮ اﺳﺖ در ﺳﻨﯿﻦ اﺑﺘﺪاﯾﯽ )8-12 ﺳﺎﻟﮕﯽ( اﺻﻼح ﺷﻮد ﺑﻪ اﯾﻦ دﻟﯿﻞ ﮐﻪ ﺑﺎ ﺑﺎﻻ رﻓﺘﻦ ﺳﻦ ﻋﻤﻞ ﺟﺮاﺣﯽ ﺳﺨﺖ ﺗﺮ و ﻋﻮارض آن ﺑﯿﺸﺘﺮ و ﻣﯿﺰان ﻋﻮد و ﻋﻮارض روﺣﯽ رواﻧﯽ ﻧﺎﺷﯽ از آن ﺑﯿﺸﺘﺮ ﺧﻮاﻫﺪ ﺷﺪ. ﻟﺬا ﺑﻪ ﻫﻤﮑﺎران و ﭘﺰﺷﮑﺎن ﺧﺎﻧﻮاده ﺗﻮﺻﯿﻪ ﻣﯽ ﮐﻨﯿﻢ ﮐﻪ اﯾﻦ ﺑﯿﻤﺎران را ﺟﻬﺖ ﺟﺮاﺣﯽ و اﺻﻼح ﺑﻪ ﻣﺮاﮐﺰ ﺗﺨﺼﺼﯽ ﻣﺮﺑﻮﻃﻪ ارﺟﺎع داده ﺗﺎ از ﻋﻮارض ﯾﺎد ﺷﺪه ﺟﻠﻮﮔﯿﺮي و ﻫﻤﭽﻨﯿﻦ از روشﻫﺎي ﮐﻤﺘﺮ ﺗﻬﺎﺟﻤﯽ ﻣﺜﻞ ﻧﺎس ﺗﻌﻠﯿﻢ داده ﺷﻮد.

Introduction & Objective: There is a large spectrum of congenital chest wall deformities mostly including pectus and sternal defects. Most of these deformities have mental and physiological effects. Reconstruction of these deformities has minimal morbidity and mortality rate and if they are repaired mental and physiological problems will be solved. Present study has been done in order to evaluate symptom and the surgery indication of various types of deformities and their treatment and results. Materials & Methods: In this descriptive study, 52 patients (38 men, 14 women) with thoracic deformity underwent reconstructive surgery in Razi and Aria hospitals. All patients except those with sternal cleft underwent CXR, CT scan, for diagnosis. Ravitch's technique was used in pectus cases; resection of rib was done for patients with prominent rib using pectoralis major muscle and mesh; and chondrotomy was performed on sternal cleft. Results: The mean age of the patient was 14.81±5.8 (range, 3 to30). The most common symptom was malformation, seen in 52 (%100) patients. From 52 patients, 32 (61.53%) of patients were pectusexcavatum, 10 (19.23%) were pectuscarinatum, 7 (13.4%) protrotion of ribs and 3 (5.7%) sternal cleft. In most of patients CXR was abnormal (73.68%). The severity of pectusexcavatum ranged from 3 to 5cm. For patients older than 15, two pins were used to fix sternum. Most patients had no surgery complications (8 pneumothorax, 4 pneumonia, 3 atelectasis and 2 bar infections). Surgery complications were mostly observed in patients older than 15. Two recurrences in PE and one in PC were happened. There was no mortality. Most of the patients had score of 6 out of 10 postoperative pains (42.3%). The score of pain was noticeably higher in older patients. Period of hospitalization ranged from 3 to 7 days. The period of hospitalization in patients older than 15 was noticeably more. Patients were followed up 2-6 years. 15(28.84%) of patients declared excellent level of satisfaction and the 35 (67.30%) stated good and 2(3.84%) didn’t have satisfaction. Conclusions: Pectusexcavatum and pectuscarinatum and sternal cleft are better to be corrected in age of 8-12 years; because as patients get older the chance of complication, recurrence, and psychological problems increases. and NUSS operation must be teaching in the teaching hospital of university.