NGOAI KH0AS6 BAC BIET 1, 2, 3/2012
DANH GIA KET QUA PHAU THUAT NUSS KET HOP NOI SOI LONG NGI/C DIEU TRj BENH NGliC LOM BAM SINH
TAI BENH VIEN VIETDLfC
Nguyen Hiru U'o'c*, Ngo Gia Khanh*
TOM TAT
Trong thdi gian tir 6/2010 den 11/2011 chung tdi da phau thuat cho 53 benh nhan (33 benh nhan nam 2010 va 20 benh nhan nam 2011) bang phu'dng phap Nuss ket hOp vdi ndi soi long ngi/c. Tuoi trung binh 16 ± 3 (5-26 tuoi), 47 nam: 6 niJ. Thdi gian phau thuat 69 ± 24 (phiit). Phan Idn benh nhan chi can dat 1 thanh dd (92,5%), 4 benh nhan dat 2 thanh, khong can phai dat DLMP trong mo, khdng cd bien chutig nang trong mo, thdi gian nam vien 1.2 ± 5.2 (4 -8 ngay), bien chu'ng sdm: tran khi mang phoi (1,9%), Tran khi dUdi da(7,5%), nhiem triing vet m d ( 5 , 6 % ) , 100% benh nhan cai thien trieu chu'ng cd nang, 100% benh nhan cai thien tinh trang long ngUc, bien chimg mudn:
di LTng thanh d d (3,7%) bieu hien bang viem ro vet mo keo dai, danh gia mu'c do hai long ciia benh nhan: Rat hai Idng 49,1 % , hai long 45,2%, Ichong hai Idng 5,7%. Danh gia ket qua phau thuat: Rat tdt 56,6%, t o t 37,7%, trung binh 1,9%, toi 3,8%.
SUMMARY
During the period 6/2010 to 11/2011, we operated on 53 patients (33 patients in 2010, 20 patents in 2011) with Nuss procedure combined thoracoscopy. Mean age: 16 ± 3 (range 5-26), 47 male: 6 female. Operative duration was 69 ± 24 mins (range 30 - 150 minutes). Most patients only needed 1 pectus bar (92.5%). 4 patients
needed 2 pectus bars. Thoracotomy tube was not needed. No complications was severe during operation. Hospitalization time was 1.2 ± 5.2 (4 - 8 days). Early complications: pneumothorax (1.9%), subcutaneous emphysema (7.5%), wound Infection (5.6%). 100% of patients with symptoms improvement. 100% improvement in the chest condition after surgery. Late complications: allergy with pectus bar (3.7%) as indicated by wound infection. Assessment of patient satisfaction: very satisfied (49.1%), satisfied (45.2%), dissatisfied (5.7%). Evaluating the results of surgery: very good (56.6%), good (37.7%), medium (1.9%), bad (3.8%)
I. OATVANOE
Benh ngirc lorn chiem ty le cao nhdt (90%) trong sd eac di dang bam sinh cua thanh ngue. Di tat nguc lom chiem khoang 1/400 ddn 1/300 tre moi.
Dieu tri ngoai khoa di tat nguc !dm chi mdi duge de xuat tir dau the ky 20.
Cac phuong phap ph^u thuat kinh dien (nhu Bruner, Judet, Ravitch cai tien...) da dugc ap dung tir lau nhimg cd nhieu nhugc diera va ket qua han che.
Nam 1997 Donald Nuss de xuat phuang phap mdi dieu trj benh nguc 16m bam sinh - Phlu thuat can thiep tdi thieu - Phuang phap Nuss, tir khi rra ddi phuong phap nay cho thiy nhilu uu diem va dang dugc thay the
DAI Hpi HQl NGOAI KHOA VN LAN THCTXII VA HQI NGHI. KHOA HOC NGOAI KHOA TOAN Q U 6 C LAN THUXIV
dan cac phuong phap phau thuat kinh dien 0 Benh vien Viet Due, Phau thuat Nuss mdi dugc ap dung tir 6/2010, nham danh gia hieu qua cua phuang phap nay chung tdi nghien cuu de tai nay nham muc tieu:
Danh gid kit qua s&m vd trung han phdu thuat Nuss kit hpp noi soi long ngirc trong dieu tri binh nguc lom bam sinh tai Binh vien Viet Diic
I), oo'l TUONG VA PHUONG P H A P NGHIEN COU
Ddi tugng: 53 benh nhan dugc chan doan NLBS dugc dieu tri bang phuang phap Nuss kdt hgp ndi soi Idng nguc tai Benh vien Viet Dire tir 6/2010 ddn 11 /2011.
Phuffng phap nghien cuu md ta cat ngang.
Cae budc tien hanh nghien euu:
Kham lam sang (khai thac trieu chimg eo nang, tien su benh...), chup XQ ngue (do chi sd LVI), CT Scanner nguc (do chi sd Haller).
Phan loai lom ngue theo Hyung Joo Park: phan thanh 3 the [6]
+ The I: Idm ddng tam IA: lom nguc ddng tam khu tru IB: 1dm nguc ddng tam dang phang + The IIA: lom lech tam IIAl: 1dm ngue lech tam khu tru IIA2:1dm ngue lech tam dang phang IIA3:1dm nguc lech tam tao kenh dai.
+ The IIB: loai lom nguc hdn hgp, cd loi va 1dm.
Tien hanh phau thuat:
+ Benh nhan dugc gay me ndi khi quan, nam ngira, dang 2 tay vudng gdc than minh, cd don gdi dudi lung.
•I- Do lai khudn Idng nguc, udn thanh do + Rach da 2 em dudng nach giira KLS V, 2 ben thanh nguc
+ Dat Trocar dng kinh ndi soi KLS VII duang nach truoc ben phai (neu tien hanh phau thuat tir ben phai) hoac ben trai (neu tidn hanh phau thuat tir ben traj)
+ Tach tao khoang dudi da + Ludn thanh hudng din tao dudng ham mat sau xuong lie duoi hudng din cua ndi soi ngue.
+ Ludn thanh da
+ Quay ngugc thanh do 180* nang xuong lie.
•I- Cd dinh thanh do vao xuang sudn bang chi thep.
+ Dudi khi, ddng vet md.
Danh gia cac chi sd trong phau thuSt:
Thai gian phau thuat, sd thanh da, dan lim mang phdi, bien chimg
Danh gia ket qua sdm sau md:
Tinh trang Idng nguc sau md, tinh trang vet md, bien chiing sdm sau md.
Danh gia ket qua trung han:
-t- Benh nhan duge kham lai sau 1 nam (ddi vdi benh nhan md nam 2010) hoae sau 2 thang (ddi vdi benh nhan md nam 2011)
+ Danh gia: Miic do cai thien trieu chiing eo nang, tinh trang Idng nguc, tinh trang seo md, mice do hai Idng cua b?nh nhan, bien chiing mudn
Ket qua phau thuat dugc chia lam 4 miic:
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NGOAI KHOA SS BAC BlfT 1,2,3/2012
Thu thap s6 lieu, xit ly s6 liSu, vilt bao cao
Chi tieu danh qia Mu'c do hai long Hoat done lim sang
the luc Long nquc Seo mo CO nanq Bien chutiq X quanq
Rat t o t Rat hai long Binh thUdnq Phanq Tdt Het trieu chirhq Khonq Met lom
Tot Hai long Binh thu'dnq Cd cai thien Tdt Het trieu chirnq Khonq Het lom
Trunq binh Chu'a hai Idnq Binh thudnq Cd cai thien Xau Cd cai thien Cd Cd cai thien
Xau Khonq hai Idnq Han che Khdnqcai thien Xau Khonq cai thien Cd mdt/nhieu Khonq cai thien
III. KET Q U A
1. Dac diem cua nhom nghiSn cihi:
Tudi trung binh: 16 ± 3 (5 - 26) tudi Gidi: Nam: 47 ; NO: 6
Da sd benh nhan cd the trang cao gay Tien sir benh long ngue:
+ Cd 2 benh nhan cd gii veo cdt sdng kem theo
+ Cd 3 trudng hgp da md theo cac phuong phap kinh didn (Bruner, Ravith)
Trieu chiing lam sang thudng gap:
Ngue lom hit thudng (100%), nhanh met khi van ddng (67,9%), khd thd khi gSng siic (39,6%), dau hieu bung phe (52,8%)...
2. Phan loai theo Park:
The IA (Bong tam khu tru) IB (Dong tam dang phang) IIA (Lech tam khu tru) IIB (Lech tam dang phang) IIC (Lech tam tao kenh dai) I I I (Hon hdp CO loi va lom)
N 33 10 5 4 1 0
%
62,3 18,9 9,4 7,5 1,9 0
3. Chi so LVI trttifc mo, sau mo:
Chi sS L V I Tru'dc mo Sau mo
Mean 0,32 ± 0.06 0,26 ± C.02
l^in 0,26 0,24
Max 0,5 0,3
4. Chi so Haller trufrc md, sau mo:
Chi so Haller Tri/cfc mo Sau mo
Mean 4,1 ± 0,86 2,8 ± 0,22
Min 2,87 2,46
Max 6,6 3,2
DAI HQI HQI NGOAI KHOA VN LAN THaxil VA Hpi NGHj KHOA HOC NGOAI K H O A T O A N Q U 6 C LAN T H J X I V
4. Cac chi so trong phau thuat:
Thdi gian phau thuat:
Trung binh: 69 ± 24 (30 - 150 phut) S6 thanh dd:
1 t h a n h 2 thanh Tong
N 49 4 53
»/o 92,5
7,5 100 Ddn liru mdng phdi trong mo:
Chung tdi khdng dat DLMP trong md Bien chimg trong mo:
Khdng cd tai bien, bien chiing nao (chay mau, tdn thuong tim phdi, mach mau ldn...) xay ra trong md
5. Ket qua sdm:
Tilth trgng long ngirc:
Thdi gian nam viin:
Trung binh: 5,23 ± 1,2 (4 - 8 ngay) Tdng thdi gian nam vien dai nhat > 3 thang
Ji
BI
Khong cai thien Co cai thien Het lom Tong nh trang vet mo:
Kho Tu dich Nhiem triJng Tong en chimg s&m:
Tran khi du'cfi da TKI^P TMMP
Nhiem trung vet mo Di lech thanh
N 0 35 18 53
N 50 2 1 53
N 4 1 0 3 2
%
0 66 44 100
%
94,3 3,8 1,9 100
%
7,5 1,9 0 5,6 3,8
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NGOAI KHOA s6 DAC BIET 1, 2,3/2012 6. Ket qua t r u n g han:
Cai thien trieu chung ca ndng.
Khonq thay doi Co cai thien Het trieu chiJnq Tonq
N 0 13 40 53
°/o 0 24,5 75,5 100 Tinh trgng long nguc:
Khonq thay doi Co cai thien HSt lom Tonq conq
N 0 23 30 53
%
0 43,4 56,6 100 Tinh trgng seo mo:
Lien seo tot Seo xau Tonq
N 49 4 53
»/o
92,5 7,5 100 Bien chihtg mupn:
Di lech thanh Tut thanh id vao KI^P
Lo thanh id Di LTnq thanh dd Tonq
N 0 0 0 2 2
%
0 0 0 3,7 3,7
Mire dp hdi long ciia benh nhan:
Rat hai long Hal lonq Khonq hai long Tonq
N 26 24 3 53
%
49,1 45,2 5,7 100
BAI HQI HQl NGOAI KHOA VN LAN THtf XII VA HOI NGHj KHOA HOC NGOAI KHOA TOAN Q U 6 C LAN T H O XIV
biet nhieu vdi cac trieu chiing kinh dien nhu y van md ta. Cac trieu chimg thudng gap:
benh nhan hoac ngudi nha tu nhan 1dm nguc (100%), nhanh met khi van dgng (68%), kho thd khi gang siie (39,6%), dau hieu bung phe (52,8%). Ket qua nay ciing tuong tu nhu IV. BAN LUAN
1. Dac diem chung ciia nhdm nghien cuu:
Tudi:
Tac gia Hyung Joo Park chi djnh phlu thuat cho benh nhan nhd tir 3 den 5 tudi vi d Ilia tudi nay khdng anh hudng den viec hgc tap va tre khdng nhd den cupc phau thuat eiing nhu d; tat ma minh da mac [6]. Tac gia Nuss chi dinh md eho benh nhan tir 6 den 18 tudi vi dng cho rang o liia tudi nay benh nhan se hgp tac dieu tri tdt lam ban che bien ehiing di lech thanh ddng thdi khung xucmg cdn mem de nang [4]. Tuy nhien cd nhieu tac gia vin chi dinh md cho cac benh nhan dudi 3 tudi va ngudi trudng thanh.
Trong nhdm nghien cim eua chung tdi, tudi trung binh la 16 ± 3. Ddi vdi benh nhan khi md 26 tudi, ehung tdi thuc hien phhx thuat eung eho ket qua tdt.
Gidi:-
Theo Y van, benh NLBS thuong gap d chiing tdc da tr4ng chiem ti le 1/400 - 1/300 tre sinh ra cdn sdng, ti le nam nhieu %ip 4 ldn nii. Trong nghien ciiu ciia Abdullah Erdof^n nam chiem 63%, nu' chiem 37%. Shu Q, Z.
Shi (Trung Qudc) nghien eim tren 406 benh nhan cd 93 nii, 313 nam [8]
Trong nhdm nghien cu'u cua chiing tdi ty le Nam/Nir = 8/1
Tien sir benh long nguc:
Chung tdi nhan thay cd 2 benh nhan cd gii veo egt sdng kem theo, dac biet ed 3 benh nhan da md nang xuong uc theo phuang phap eu (Ravitch, Bruner) khdng kit qua, lom nguc tai phat ddn md lai, nhiJng benh nhan nay qua trinh phlu thuat thuang khd khan hon vi phai go dinh mat sau xuong lie
Trieu chiing lam sang:
Chiing tdi nhan thay eac bieu hien lam sang ciia nhdm nghien eiiu khdng cd su khac
trong nhieu nghien cim khac 2. Phan loai lom nguc theo Park:
Cac nghien ciiu deu nhan thay the nguc 1dm ddng tam la hay gap nhit. Cach phan loai nay dugc Hyung Joo Park (Han Qudc) gidi thieu nam 2004, iing dung eho ky thuat tao hinh thanh nguc theo phuong phap xSm nhap tdi thieu eua Donald Nuss (My), va nhanh chdng duge ap dung tai cac trung tam phau thuat d Chau A (Viet Nam, Dai Loan, Nhat, Singapore, An Do, Trung Qudc...).
Trong nhdm nghien cim ciia ehiing tdi da sd benh nhan 6 the 1dm ngue ddng tam (doi xiing hoae khdng ddi xung) chidm 81,2% thi nay thudng ed ket qua dieu tri tdt.
3. Chi so LVI truoc md - sau mo:
Tat ea 53 benh nhan deu dugc chup XQ ngue thang, nghieng.
Trong nghien cim, chi sd ngue thdp: LVI
= 0,34 ± 0,07, thap nhat: 0,26, cao nhat: 0,5.
Ket qua nay ciing tuong tu nhu nghien ciiu cua Nguyin Van Trudng (0,35 ± 0,047; 0,28;
0,48) [2].
Chi sd LVI do sau md dugc 42 benh nhan voi kdt qua: 0,26 ± 0,2. Kidm dinh T test theo cap cho thay cd su khac biet cd y nghia thdng ke so vdi truoc md.
4. Chi so Haller trudc md - sau mo:
Trong nghien ciiu ciia chung tdi Haller trung binh 4,1 ± 0,7, nhd nhdt 2,87, ldn hhk 6,6, trong sd dd ehi cd 18 benh nhan dugc ehup lai CT scanner kiem tra. (2,8 ± 0,2). So sanh vdi kk qua sau md, eho thiy cd su khac biet cd y nghTa thdng ke vai p < 0,001. '
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NGOAI KHOA Sl5 BAC BIET 1, 2,3/2012 Cac nghien ciiu deu chi ra chi sd Haller
6 benh nhan NLBS cao hon cd y nghia sd vdi binh thudng (binh thudng 2,5). Va nhiing trudng hgp chi dinh md da phan cd ehi sd Haller > 3,25, tuy nhien ehi dinh md khdng phai chi dua vao ehi sd Haller ma cdn kdt hgp vdi cae yeu td khac nita nhu: mire do anh hudng den sinh boat, nhu cau tham my eiia benh nhan...
5. Cac chii so trong mo Thdi gian phau thuat:
Thdi gian phau thuat eiia chung tdi trung bmh: 69,4 ± 24,4 (phut), dai nhat: 150 (phiit), ngan nhat: 30 (phiit). Theo tae gia Anthony J.
Bufo thdi gian phau thuat trung binh la 68 phiit (40-85 phiit), theo A. Nicodin thdi gian phau thuat trong khoang 60 - 80 phiit. Cae nghien ciiu trong va ngoai nude d^u chi ra rSng thdi gian phau thuat eua phucmg phap Nuss dugc nit ngan rat nhieu so vdi eac phuong phap kinh dien truac day (Bruner, Ravicth...) Nghien eiiu eiia Nguyen Van Trudng cho thay: PP Bruner vdi thdi gian trung binh: 124 ± 37 phut; PP Judet vdi thdi gian hung binh: 118 ± 37 phiit; PP Ravitch cai tien vdi thdi gian trung binh: 100 ± 10 phiit; PP keo lien tuc vdi thdi gian trung birJi:100 ± 2 8 phiit [1]
Sd thanh d5:
Trong nghien cuu cua ehiing tdi, da sd cac trudng hgp chi can dat mdt thanh da (92,5%), chi cd 4 truang hgp phai dat 2 thanh. Viec dat 1 hay 2 thanh da tiiy thugc vao the 1dm nguc (the 16m ddng tam thudng chi dat mgt thanh, the 1dm rong tao kenh dai thudng can nhic dat 2 thanh), liia tudi va do Cling eiia thanh nguc tre (tac gia Nuss dat 2 thanh d nhtmg benh nhan ldn tudi); thanh nang thii hai d phia tren chang nhiJng giiip cai thi?n kdt qua dieu chinh bien dang, ma
cdn ban che bien chiing di lech thanh sau nay.
Dan luu mang phdi trong md:
Trong nghien ciiu ciia chiing tdi khdng ed trudng hgp nao phai dat DLMP sau md.
Mdt sd phlu thuat vien chu truang dat DLMP 2 ben dd du phdng. Donald Nuss dat DLMP d 3 % benh nhan ma dng phlu thuat, theo K.A. Miller cd 2,4% trudng hgp phai d§t DLMP sau md. Trong nghien eim ciia Vii Hiiu VTnh: CJ nhung trudng hgp khdng dat dng dan lim khoang mang phdi, bien chimg tran khi khoang mang phdi 2 ben 2 trudng hgp va tran mau 1 ben 1 trudng hgp [2].
Bien chimg trong md:
Trong nghien ciin ciia chiing tdi khdng ghi nhan trudng hgp nao cd bien chung nang.
Hyung Joo Park md ta mot trudng hgp thiing tim trong 322 benh nhan dng phau thuat [8]. Gips H thdng bao mdt trudng hgp thiing tim trong md [6]. Tom N. Hoel md ta mdt trudng hgp thiing DM chii sau md 2 thang den vien vdi hdi chiing ep tim cap [10].
Marusch F thdng bao mdt trudng hgp thung CO hoanh gay thoat vi lach va dai trang Ien nguc.
6. Ket qua som:
Tinh trang Idng ngue:
100% benh nhan cua chiing tdi cd cai thien tinh trang long ngue ngay sau md trong dd 44% benh nhan het 1dm hoan toan, sd cdn lai cai thien d cae miic do khac nhau
Tinh trang vet md:
Mot trong nhu'ng diem ldn ciia phau thuat Nuss la dudng md nhd, cilng vi the ma viec eham sdc vet mo don gian hoit nhieu so voi trudc day va ty le nhiem trung vet md giam di ro ret. Chiing tdi ghi nhan duge 3 trudng hgp cd bieu hien nhiem triing vet md, trong do 2 benh nhan nhiem trung ndng dieu tri khang sinh, thay bang hang ngay sau dd
DAI HOI HQI NGOAI KHOA VN LAN THCTXII VA HQI NGHI KHOA HOC NGOAI KHOA TOAN Q U 6 C lANTHaXiV
on djnh. Cd mdt benh nhan nhiem triing vet md nang phai ra vao vien lai sau > 1 thang dieu tri them sau dd 15 ngay.
Bien ehiing sdm:
Ty le bien chung sdm (trong 1 thang sau md) la 20,8%, trong dd nhiem trimg vet md 3 trudng hgp, 1 trudng hgp TKMP phai dat DLMP, 4 trucmg hgp cd tran khi dudi da canh vet md nhung khdng can xir tri gi, 2 trudng hgp di lech thanh theo phuong nam ngang ngay sau md do xac dinh nham khoang lien sudn trong md.
Thdi gian nam vien:
Thdi gian nim vien eiia benh nhan trong nhdm nghien eiiu eiia ehiing tdi trung binh la 5,2 (ngay), tuong duong nhu eiia cac tac gia khac trong va ngoai nude. (Tran Thanh Vy:
6,11, Qiang Shu: 7 ngay).
Phlu thuat Nuss la phuong phap mdi dugc ap dung nhung da nhanh chdng thay the cac phau thuat kinh dien, do cd nhieu uu the mdt trong nhiing im diem la hau phau nhe nhang, nit ngan thai gian nam vien
7. Ket qua trung han:
Cai thien trieu ehiing ca nang:
Trong nghien eiiu eiia chiing tdi, 100%
benh nhan cai thien trieu chiing eo nang sau md, het han trieu chung chiem 75,5%.
Tinh trang seo md:
Nghien ciiu eiia chiing tdi cho thay da phan benh nhan hai Idng vdi tinh trang seo md 92,5% benh nhan cd seo md lien tdt. So sanh vdi ket qua cua Nguyen Van Trudng, nghien cim ket qua dieu tri theo phucmg phap cii ed tdi 50% seo md xau
Tinh trang long ngue
Ket qua kham lai eho thay 100% benh nhan cd eai thien tinh trang lom nguc 6 eae miie do khac nhau, trong dd ed 56,6% het 1dm. Nghien cim ciia Nguyen Van Trudng md theo phucmg phap eii chi 13,6% het lom.
Phucmg phap Nuss moi dugc ap dung nhung da eho thAy kh qua hon ban eac phuong phap cu.
Bien chiing xa:
Cd 2 truong hgp di iing vdi thanh do chiem 3,8% diku tri ndi khoa nhieu lan khong ket qua phai md thao thanh do, 1 trudng hgp nhiem trimg vet md dieu tri bao ton thanh cdng. Khdng gap nhijng bien chiing khac:
Viem mang ngoai tim, TMMP...
8. Danh gia ket qua phau thuat:
Chiing tdi danh gia ket qua phau thuJit dua vao: Tinh trang cai thien trieu chiing co nang, do 1dm long nguc, tinh trang seo m6, miic do hai Idng eiia benh nhan
Ket qua tdt va rat tdt ciia ehiing toi chiem 93,3% phii hgp vdi nghien ciiu cua nhieu tac gia khac tren the gidi, nghien ciiu eiia Park ed tdi 91.3% loai rat tdt. So sanh vdi nghien ciiu cua Nguyen Van Trudng cho thay Phau thuat Nuss cd ket qua tdt hon han so vdi cac phuang phap dieu tri ed dien ket qua dieu tri loai trung binh va kem chiem gan 50%.
V. KET LUAN
Ket qua sdm va trung ban cho thay Phuang phap Nuss ket hgp ndi soi Idng ngirc ed nhieu uu diem trong dieu tri Benh NLBS:
Tham my, thdi gian phau thuat, thai gian nam vien ngan, ket qua cai thien trieu chtmg CO nang, eai thien long nguc tdt.
TAI LIEU THAM K H A O .
1. Nguyin Van Truong (2010), "Nghien ciru danh gid kit qua phdu thuat di dgng nguc lom bam sinh tai benh vien Viet Due", Luan v5n Thac sy, Truong Dai hoc Y Ha Ndi.
2. Vu Hiru VTnh, Ngo Quoc Hung &
Chau Phu Thi (2011), "Phdu thuat can
248
NGOAI KHOA s d eAC BIET 1, 2,3/2012
thiep toi thieu chinh sua benh lom nguc bam sink bdng thanh ndng nguc. ", Hdi Phlu thuat Tim Mach & Ldng Ngue Viet Nam.
Tran Thanh Vy (2008), "Kit qua dp dung ky thuat Nuss dieu tri lom nguc bam sinh". Tap chi y hgc Viet Nam, Tdng hdi y hgc Viet Nam tap 352, pp. 590-595.
Tr^n Thanh Vy, Le Phi Long & Tran Thi IMai Thiiy (2008), "Diiu tri di dang thanh nguc tai Binh vien Dgi hoc Y duac TP H6 Chi Minh", Phu ban eua sd 4, Nghien eim Y hge, Y hge TP Hd Chi Minh, tap 12.
Donald Nuss (2005), "Recent experiences with minimally invasive Pectus Excavatum repair 'Nuss procedure'", Thorac Cardiovasc Surg, 53, pp. 338-344
Gips H, Zaitsev K & Hiss J (2008),
"Cardiac perforation by u pectus bar after surgical correction of pectus excavatum: case report and review of the literature ", pediatric surgery, 24(5), pp.
617-20.
7. Hyung Joo Park, Seock Yeol Lee, Cheol Sae Lee, Wook Youm, vd cs (2004), "The Nuss procedure for pectus excavatum: evolution of techniques and early results on 322 patients ", Arm Thorac Surg 77, pp. 289-295.
8. Hyung Joo Park, Seock Yeol Leea &
Cheol Sae Leea (2004), "Complications associated with the nuss procedure:
analysis of risk factors and suggested measures for prevention of complications", Joumal of Pediatric Surgery, 39, pp. 391 -395.
9. Qiang Shu, Zhuo Shi, Wei Ze Xu &.
Jian Hua Li (2011), "Experience in minimally invasive Nuss operation for 406 children with pectus excavatum", World J Pediatr, 7(3), pp. 257 - 261.
10. Tom N. Hoel, Kjell Arne Rein & Jan L. Svennevig ( 2006 ), "A Life- Threatening Complication of the Nuss- Procedure for Pectus Excavatum", Aim Thorac Surg 81, pp. 370-372.
