All right, we are back. I'm going to turn this over to Dr. Stephen Lee, who's going to lead this session on Pactis Excavatum. Great. Thanks, Todd. Thanks for having me today, and welcome to everyone around the world. Good morning here. It's 8.30 in the morning. You see some sunshine across because the sun's rising here. But good evening, good afternoon to wherever you are. We're really excited to have this session. As Todd said, there's no debates whatsoever, so we'll jump right into it and then start the polling questions with a quick case. So before we do that, the agenda, we're going to discuss some perioperative pain control, and then we'll do some rapid-fire updates with techniques, and if we get to it, some rare cases. So this is a 16-year-old young man with shortness of breath on exertion. He has no comorbidities, and his Pactis Index is 5.5. You can see a photo and a CT scan. The plan is to do a chest wall reconstruction with a NUSP repair. And the first question is, in addition to multimodal pain medication, what do you recommend for perioperative pain control? Pryoanalgesia, perivertebral indwelling catheters, thoracic epidural catheter, perivertebral blocks, or no additional modality. So while this is going up, while we're pulling this, getting the questions and answers up, I'll just pick on someone really quickly. Rob Rick, what do you use at your institution? I figured you'd catch me. So my answer is not up there. I personally use on-Q pain pumps. I know there's some data suggesting infection rates. I've not seen that personally, and I've liked that. Although I will tell you, I did my first cryotherapy two weeks ago, and I thought it was outstanding. So I think I'm a believer in cryotherapy. Great. And what does our poll suggest, that one? Yeah, most people are saying cryoanalgesia, 63%, and the next most common is thoracic epidural catheters, 24%. Okay. So not a clear consensus, and it seems to be a moving target. So let's discuss this and debate this. We're going to go by some standard debate rules and try to limit this to five minutes max per person. And let's start with the most popular one with cryoanalgesia. So Sean St. Peter, can you give us a reason for doing cryoanalgesia and the support behind it? Yeah. Do we have the slides, or am I going to screen share here? No, we have your slides. Excellent. So I started with this slide just to explain the pickle that we were in. We, of course, struggled with postoperative pain management, as everybody did. This is the most painful thing that we do to children. Any anesthesiologist will tell you that, even more so than the spines. And we had completed a randomized trial, 110 patients to epidural and PCA. And in that study, you see the maximum pain scores there, AM and PM. And the epidurals didn't really drop off, and that's because that day two, day three transition leads to more pain, as opposed to going ahead and overloading the sensory receptors. And then you get the attenuation, and the pain slowly goes down. So in the PCA group, the pain we saw going down over the course of four and a half days, not so much in the epidural. Now, we as the surgeons looked at this. And when I presented it, I think it was Dave Natryka who said, this is the final nail in the coffin for the epidural, because there has to be an advantage to something that is time consuming, is an extra procedure, and imposes risk, as opposed to the IV that they get anyway for the operation. The anesthesiologists look at the same data and say, we need a better epidural. So literally, that was the response of our anesthesiologist who saw this and said, well, we just have to figure out a better transition plan. So we started a second randomized trial, along with Madison, Wisconsin. And the anesthesiologist had some measures to try to salvage catheters that weren't working very well. They put in a more robust transition plan, big dose of Duramorph before they pulled it out. And in the epidural group, I mean, in the PCA group, we added a better bowel regimen, because we found that seemed to be the thing that kept patients around the PCA group. So we were enrolling in this study, we had about 30 patients in each group, when we tried the first cryotherapy. And when that patient went home on post-op day one, equipoise was lost. So we started a prospective observational study. And this is how we do the cryo. We can go back to the first picture just to show how simple it is. If we rewind, sorry, a couple of slides. Yeah, the... Wow, we're flying now. So the technique is easy, but the slideshow is not. The technique is actually impressively easy. I'm going to see if I can get the slide link to work. Sean, is it a video you're trying to play? Nope, that's good. That's it. That's the picture. I was just going to show that the camera can go on either side. It can go at the top or the bottom. One trick that we've learned is to just make them one inner space apart. So wherever you put your camera, don't go in the same line, but go below it or above it for pushing the cryoprobe through. And the way we typically do it now is that the... I think the slides are going crazy. I think maybe tell them, Sean, what side you want it to be on, and they can get you there. Those are my slides. Yeah, if you can back it up. There we go. Okay. So that's the picture that I was talking about. We currently put the camera on the top and the probe through the bottom, but you can see how they're separated. One's an inner space above. That just keeps them out of each other's way. And you literally just count down to the fourth rib and then freeze underneath it. It's two minutes per rib. We do four through seven. You're not supposed to go eight or below because you can get some abdominal wall paralysis, which is kind of a funny story. I did a bilateral slipping rib. We were just starting to do the cryo. Now those are low. So I went ahead and froze the nerves. And when she stood up, her upper abdomen just kind of pouched out. And she goes, is that normal? I was like, that should go away in a little bit. It took a few weeks, but it did go away. So we don't go below eight. And what we did is start a prospective observational study. So while we were doing the IRB, we went ahead and took that cohort, the retrospective cohort of nine, and we presented that at IPEG in 2018. And there was an audible gasp when we said that six of the nine went home on day one. And so from there, that's when I started getting a lot of emails, a couple of people came out to watch us do one. And now it's kind of picking up in the literature with quite a bit of speed because the Delta is so big. And what we saw there is the length of stay where we just couldn't get below four days, all of a sudden became one. And it's either works or doesn't work. That one is impressive because you see that the range is tight and that is created just by a few failures. So it's not like sometimes it's one and sometimes it's two. It's one or four. And so the occasional failure ends up looking just like they used to and they go on a PCA. And then, of course, the thing that is popular now is what impact we have on our median morphine equivalents. And they're not even really on the same planet. And I was trying to get a video clip from the video that we're showing in the ads. And if anyone's had a chance to see the ads roll, there's a kid there that flexes. And that is a post-op day one pectus. And so I took a picture. I paused it and took a picture so I could show the group. But there's the kid. That's post-op day one. And he's standing there with his shirt off flexing. And this is after he got out of the shower. And so his brother had a pectus repair two years earlier. And the dad says, we had a video on this that was inside pediatrics. And the dad says, you know, when Samuel had his, it took him two weeks before he could put his own shirt on. And he goes, this morning, Jacob took a shower, put his own shirt on. And so, and just like Rob said, once you see it, it's sort of a different game. Wow, that's great. I mean, that's really compelling. For those who have done it, will really notice the difference between cryo and any other pain modalities. But I think there are some skeptics out there. And I think Vic Garcia has mentioned that he's not a big believer in cryo and then uses another technique. So Vic, do you want to go ahead and give us a reason why not to use cryo? Yeah, sure. Well, actually, I agree with Sean. It works. I mean, it is great. One day. Yeah, no. So what I'm concerned about is, is that there are no long term studies. And so I don't believe it's ready for prime time. And I think however it presents an opportunity, and you can go to the next slide, please. I come to this perspective from really an article by Jerome Grootman in the New Yorker, that then led me to a book, which I would argue everybody who's doing innovation in this space ought to read. And that is a expose as far as the abject failure, as far as how really the FDA and the government are monitoring the introduction of medical devices. And that book is, again, for your references, the danger within us. You know, unlike drugs, medical devices and implants are not, are not required to undergo clinical trials before they're introduced into the market. And that is indeed the case with a cryo ice or cryosphere. Now, some of these innovations pan out to be quite lifesaving and certainly quite, quite beneficial. But I believe we just don't know. We don't have the long term data. We have short term data. And we have small populations, but we don't have long term data. And as somebody who has been in this work for some decades, I remember when Ravage was introduced, and then we were doing it in you know, adolescence, and then we went into smaller children. And then we find ourselves in with acquired thoracic, you know, dystrophy, and asphyxia, among other things. And this, and it's not just about that. If you go to the next slide, please. What? Next slide. So in the danger within us, there are a whole host of medical innovations that were purported to be absolutely the cat's meow. And then over the long term, were termed to be just abject failures. Okay. Actually deaths, not just bad outcomes. Next slide. And so we, in my judgment, did not have then the data that would suggest that what happens in the long term. And yes, Sean shows us about this one child who comes up and is able to flex it. But there are also cases in social media who are talking about the fact that they're on gabapentin. And when is this terrible nerve pain going to disappear? And so we don't have what's happening then in the long term. And, you know, these high, what I consider high risk sort of devices do not undergo clinical trials before they're introduced. Next slide. And so what is clear is that the kind of approval, the 510k that was introduced, that led to the release of the FDA approval label for this device was not something based on clinical trials. It was something called a predicate. And that is that because it was similar to something that was introduced literally as early as 1976, it is given FDA approval. And so you have that actual cure saying, you know, this is FDA approved, but it does not demonstrate that it has been subjected to long term clinical results. How many patients, okay, in real world conditions, next slide, are going to end up with chronic pain and actually the outcomes are going to be worse than what we had hoped and intended. And I would encourage others to look at this hidden FDA report coming out of the Kaiser Health Network, as far as illustrating what I'm what I'm commenting about. Next slide, please. So the the opportunity that this presents and this is our data of some 300, well, about 100 patients looking to Sean's point as far as and this was a comparison between epidurals as well as not para vertebral, but erectospine catheters and our hospital stays are two days. We've been able to reduce the opioid requirements, not only in the hospital, but also outside of the hospital. So I'm from the perspective, at least with our experience that we do have an alternative. Is it going to be one day? No, but is it certainly much less than the four or five days that we saw with epidurals? Absolutely. Yes. So what's our opportunity? What do I feel very, very conscientious about? Next slide, please. And that is, that is the case for a registry, right? How do we know how this works? Not just in Sean Peters hands or in Latrika's hands, but in real world conditions throughout the world. And if we're going to embark on something that really has long-term potential, long-term consequences, I argue that we ought to be doing this as a registry and that this organization, the group here, would contribute significantly, not to the short term, okay, because you burn a nerve, you kill it, you hope that it regrows. We know that there's going to be that analgesia, but what happens long-term? And, you know, we just heard from the cancer experience, but even though we can cure kids with cancer, there are consequences that are long-term. And we're not going to identify those, but we should be recognizing these. And I think that that's an obligation that we have as we move forward, okay? If we're going to do this stuff, then I think we ought to be part of a registry and we should also work together to come up with a randomized controlled trial, adequately powered, okay, of sufficient duration so that we can with confidence tell our families that not only are they going to be comfortable with in the short term, but that they're not going to end up with opioid addiction in the long term because of chronic neuropathic pain, which has been reported with cryo-anogenesis. Next slide. If this is a picture of Moniz, actually, you may be familiar with him. He won the Nobel Prize for the introduction of something called lobotomy. And there were some 50,000 individuals that underwent lobotomy. It was the cat's meow. It was the cure for mental illness. And there were about 20,000 that were done. The most famous actually was Rosemary Kennedy, okay? And what he did is that his first case was an ice pick from his tool chest, and he went periorbitable and actually sort of with the leucotomy just meant just blind approaches into the frontal lobe. And unfortunately, with Rosemary Kennedy, she was no longer able to be independent and was then hospitalized and institutionalized. My hope, next slide, is that we don't find ourselves in the long term sort of dealing with unintended consequences because we didn't take the initiative to do this one in a randomized fashion looking forward and also as part of the registry. Great. So what I'm hearing is you're a believer in that it works, but you're not sure that the long term efficacy and safety has actually been worked out yet. I am absolutely convinced it works. I mean, you know, you've killed a nerve. I mean, you know, there's we're layering degeneration. You've killed a nerve. What we don't know, and I challenge anybody on this panel to tell me that they're not long term consequences. And what are we going to do about that? So let me, as a good moderator for debates, Sean Seceter, you have a 30 second response for that long term. Yeah, so it was interesting because it looked like it looked like Vic took at least a major portion of the concepts of the typical ground rounds I give and mixed up the slides a little bit. But I go through the exact same thing and even use some of the same examples, including the lobotomy, when I make the argument for why we need prospective randomized trials. But I do use the example of minimally invasive surgery and cryo kind of falls into that where if the leap is so big, that how can you then ethically randomize when you already start with such a radical difference in outcome? And one of the answers is with prospective observational studies. So the delta on the outcomes is already very large. Now the question is, what's going to be the long term impact and what's the incidence of potential side effects or symptoms going down the road? And in that we need to do it as a prospective observational study, which is why once we started doing it, it was just until we had enough paperwork to get in place that now we follow all these patients for three years and beyond. And what we're finding is that they actually don't get as much of nerve death as they get stunned because I'm impressed with how many kids have normal sensation, even in the early post-op phase, two, three weeks that they can feel their anterior chest. We also know that when you have a bar placed, you're going to have potential sequelae downstream, independent of your pain modality, pain, popping problems, people who require narcotics. And we saw all of that well before cryo was ever introduced. And so finally, I would say what gave me the leap to be able to move to the prospective observational study without other things in place is the adult experience using cryotherapy with thoracotomies going back 20 years. And we've had so many patients treated over such a long period of time without an opportunity to see a high enough incidence to make me back away from that large of a treatment advantage. Great. So I would argue that we do need a registry. You know, the cryo-algesia in St. Peter's hands and, you know, our hands, yes. But what are the real world conditions when we think about this being the most common chest wall abnormality? And Sean, I mean, I think we need to have a registry so that, you know, we work with the spine folks, we're the spinal tethering project. That is something that is actually the only way that you can go ahead and be approved by Biomed Zimmer for this is if you're part of a registry. Why don't we have a registry for this? Well, before we answer the registry discussion and discuss that further, I want to switch topics to using nothing else at all but multimodality pain medication and maybe some local blocks. And this would avoid any registry, any long-term problems, because are we changing a short-term problem of acute pain to a long-term problem? So let's discuss our third arm of medical, of post-operative pain management. And that's almost an ERAS protocol. We talked about ERAS earlier and see what that looks like. So with that, I want to invite Dr. Justin Wagner to discuss this topic. And he has five minutes as well. Although I do have to say the others did go a little bit long, but we'll try to limit it to five. Justin. Great. Thanks. I'll try to speak fast. So we're starting on this slide, which shows what are some of the most common elements of protocols that are out there when you take all range of anesthetic catheters and cryoablation off the table. The ones that you see in bold are the most commonly reported. This is from 22 studies between 2016 and this year. It looks like, you know, Tylenol and NSAIDs are already widely used. Prestidex can help for a gentle wake up. A dose of dexamethasone can help with post-anesthetic nausea. Ketamide in the hands of someone who's used it might be a good way to avoid opioids. And if you have child life specialists, mindfulness resources, and a supportive group of physical therapists, they can be enormously helpful. Benzos aren't a fixture everywhere, but muscle relaxants can help with the pain of chest wall and back muscle spasms. But here in this slide, really what this is highlighting is the elements that aren't emphasized enough in the pectus literature, but that have a pretty good body of evidence from elsewhere that supports using them. Pre-op counseling obviously has been emphasized in pectus papers, but it's so critically important to set expectations about pain that I do think it's worth hammering that point home. Gabapentin, methadone, and clonidine have all at some point been described as game changers by the ones who have used them in their pectus protocols. Gabapentin seems to be the most commonly given once in a pre-op and then for a short course post-op thereafter about 200 to 300 milligrams, three times daily for up to a week. Those sticklers about pharmacokinetics would argue that that should be started several days before the operation to reach peak effect in time. Methadone and clonidine are considerations at any phase of care, bowel regimens and antiemetics or indirect analgesics. But again, as long as they're in a protocol, they're addressing common contributors to post-op pain. And if we can advance to the next slide here, the biggest problem with not using cryo or continuous regional anesthetics, pain management, and the amount of opioids consumed, there's really only a handful of studies that report these numbers in the absence of cryo or regionals, but these are the reported distributions of morphine milligram equivalents or MNDs that are consumed. Length of stay probably accounts for a good bit of this. One study from Texas Children's this year reported 50% of patients still take opioids two weeks out from their NUSs. But that said, prescribing patterns community to community are highly variable. And the strong position statement that came out in Janus surgery last year by Lorraine Kelly-Huan and colleagues brings up the point that opioids can and should be taken out of the equation altogether for NUS procedures whenever possible. Next slide, if you could. Hospital length of stay. This goes to show you how much attention has gone into these protocols lately. Just in the past five years, we've effectively cut length of stay in half. And while cryo proponents will tell you that that's the secret sauce, some centers don't use it at all. In Nebraska, where I trained Steve Rayner, started a protocol without epidurals, catheters, or cryo, will tell you the length of stay there is under two days still for most patients. And they're off opioids by one week. Operating time is less when you don't have to wait the two minutes per inner space to freeze. And that itself translates into some cost savings in the hospital charges when you look at OR time alone. Next slide, please. So imagine these numbers as a baseline set of complications for NUS procedures. And clearly, pain control is the most common problem. And as long as the system is protocolized to minimize that, it's correctable. We've all heard about cryo and catheters. And so just keep in mind that without them, allodynia, neuropathy, and bar slippage or flippage are really uncommon. And in that Texas children's study from this year, it seems to suggest that urinary retention is a lot lower in the cryo group versus non-cryo, 8% versus 34%. But then bar flippage occurs almost eight times more commonly in the cryo group. And allodynia, neuropathy, occurs about six times more frequently in the cryo group. And that's with a relatively short, but as long-term as we have, follow-up. Next slide, please. So in summary, protocolize, set expectations, think about these particular medications, minimize opioids, embrace physical therapy and mindfulness, and really think about the types of pain management costs and complications of any strategy that your practice setting and your community can support. Great. Thanks. Great. Great. So if I heard you right, with your multimodality regimen, just of the counseling and the pre-medications and so forth, your length of stay is two days. Very similar to cryo, very similar to everything else. And you don't have the potential long-term issues. Is that what I heard correctly? That was my experience when I was in training there in Nebraska, and that's unpublished data so far. So they should be publishing pretty soon, is my understanding. But I think this is something that probably varies institution to institution. And there's no single set ERAS protocol. There have been several that have been published lately. And who knows, that may also be patient selection. It's a very community-specific issue. Great. I think we've heard all the different points of views. The interesting thing on the poll itself, it looked like to me, the highest response for postoperative pain control was epidural catheters. And I'm wondering from the panel here or anyone else in the audience wants to advocate for epidural catheters, even hearing what we've just heard today. Hey, Steve. So this is Whit. I think I'm not going to advocate for epidural catheters. I'm going to actually advocate against them. But in the literature that Sean showed in that randomized trial, the epidural could either not be placed or was removed after one or at the end of one day in like 25% of the patients. So I think it's important to realize that there are issues with epidural catheter and actually placing them. And there also have been anecdotal reports of significant complications with them. Certainly not everyone has significant complications, but there are a few anecdotal reports of significant complications with them. Okay. Any other thoughts on epidural catheters? Yeah. So Steve, in our experience, we had a very high success rate with epidurals. But we have been, we have the erector spiny catheters, our experience with that that has resulted in our, you know, that, that approach supplanted the epidural. So we no longer offer epidurals, given the results that we have with the erector spiny catheters. Can you, can you, I'm not familiar with the erector spiny catheters. Can you, can you? Yeah. So very, very briefly, erector spiny catheters, they, they, they, they're, they're placed by the pain team. And they are placed with ultrasound guidance. They're not in the vertebral space, but they are juxtaposed to it. The faith, the family, those catheters stay in for five days, the hospital stays two days, third day, while they're outside, then their hospital catheters are pulled out by the family. It is on a pump, it's automated. We did not have, we did try the on cue pumps, we did have infections associated with that, but we're not having, we didn't see that infection rate with these erector spiny catheters. And the data that I showed you in the presentation was for the erector spiny catheters compared to the epidurals. Great. Great. And I think somewhere was mentioned paraphertebral blocks. Does anyone have any experience with those? I use those in Nebraska, and it was a single paraphertebral block that was placed during the case, just before incision, done by anesthesia under ultrasound guidance. That in combination with the ARS protocol is pretty effective. Great. And kind of back to the cryo, I'm so concerned. I heard in one of the talks that there's an eight times higher bar footage rate. I wasn't familiar with that. Is that in your experience, Sean? I mean, you have that guy flexing on day one, you have him bench pressing on day two, or what's going on? Yeah. So I was kind of hoping the concept of restrictions would come up because we've come to the conclusion that when bars flip, it's always technical. And that's been what we've found. You go back to the OR and you'll find a reason why it flipped and it's not the patient. So we've had patients go back to bull riding, boxing, football, hockey, literally everything that you can do, they do it. And they've taught us. So we've now limited restrictions that beyond two weeks, you can start getting back to anything you can handle. But I would say that if a bar flips, I would look at the bar placement first and not the pain modality and not their activity restrictions. So this is what I love about this. I'm going to use Todd's line. I think I just learned something really new. So at two weeks, you let people go and do whatever they want. I mean, bull riding. I mean, we don't see bull riders here, but maybe we see skateboarders and snowboarders and surfers. You would let them do all that two weeks after because they're dying to do it. And they keep asking me. So, so yeah, as able. And of course, at two weeks, they're not going to be able to do those kinds of things. I tell them to start with, with controlled activities, like shoot baskets by yourself, but then make sure you're comfortable doing that before playing in a game or playing against other people where you have uncontrolled activities, start with cables and then go to free weights, that sort of thing. But we got together as a group because we had such widely discrepant restrictions. The nurse practitioners were going crazy. So we just all came together and came to the conclusion that if a bar is going to flip, it's going to be because how you placed it. And you see that when you have a kid that's got a loose stabilizer and you go back to take it out, like a month out from surgery, and it's, it's stuck in there. So typically if bars are going to flip, they're going to flip early. And it's going to be because they were sitting in a, in a funky inner space, they were sitting in a bad spot. The bar wasn't wrapped tight enough or it wasn't secured well. And even then I would say it's not the securing that does it. That bar's got to sit in a comfortable position before you start to secure it, or it's probably not going to stay there. Anyone else have thoughts on that? Thank you. Gary, when Jerry and you, uh, approached me about his early experience with this, uh, he made the observation that bars were flipping, uh, because they were not experiencing any discomfort. Uh, and so he then added a series of restrictions as far as activities are concerned. Um, so to hear Sean say that two weeks, I mean, that's, that is pretty good. And I'd love to know how you stabilize it, Sean. This Steve Rothenberg, I, I was a cryo, uh, uh, skeptic. Um, but we, and I'd planned to go out and see Sean, uh, do some, and then COVID came. So we finally progressed with it just on our own, which the technique is pretty easy. My, my biggest issues were with it were the added time. For those of you who know me, any added time in an operation is painful. Um, we now do the New York time crossword while we do the cryotherapy. So that's one suggestion to help. The other is concerned about the neuralgia and the complications that I'd heard about. And I will tell you that it took me about four cases to realize because most of our patients went home on day two or three, but it's not just when they go home. It's how they feel when they go home and the cryo, it's been unbelievable. I mean, I, I, um, feel bad that I waited so long. I accept VIX, um, concerns and criticisms. And I agree, perhaps, you know, that we do need to have a registry for this, but it has totally changed the management of these patients. Um, and I do think that bar flippage is completely a surgical issue. It doesn't have to do with, um, we, I'm not quite as aggressive as Sean. We wait about a month and let them, um, start being more active. But I think of a bar flips, it's because it wasn't placed in a stable position. And I don't think the amount of pain that the, the patients are feeling has anything to do with it. The other thing I've been impressed with is that when these patients come back to see us at two weeks post-op, and then, um, we see them again at six weeks, that they really don't seem to have any notice their chest wall numbness. You know, it's not an issue. Um, and granted that, you know, since we've started it relatively recently, it's, it's not a large number of patients. It's about 15 patients, but it's, it's impressive how little they notice, uh, that. So my concern about long-term consequences are pretty low and, and we are sending 70% of our patients home on post-op day one without narcotics. So it's really been a dramatic change. Right. Great. Well, well, I want to wrap this part up because we have, uh, another, uh, full session, uh, uh, with, uh, further updates, but just to summarize, uh, really quickly, it seems like cryo has been a game changer as far as decreasing narcotics, decreasing length of stay. Um, it seemed like most people believe it works, and it works very well. However, there is significant concerns about potential long-term consequences and that a registry may be what's needed and something that we can, looks like, we easily do. Um, by way of the poll questions, it seems like there's people still using epidurals and other modalities, and if there's not availability to cryoanalgesia, then a good alternative is an ERAS protocol looking at careful counseling, preoperative medications, uh, and expectation control, which can still decrease, um, uh, length of stay and decrease use of opioids post-op. So with that, unless there's any, any other discussion on post-operative pain control with, uh, with, uh, following a NUSC procedure, I'd like to move on to the other hot topics. So I'm gonna advance the slides. Uh, I'm gonna, I'm gonna bypass this for the sake of time. I wanted to see what we, uh, what any, uh, new poll results, but let's go over the technique. We mentioned, we talked about potential, um, bar techniques. It's a technique issue as far as, uh, placing the bar, and that's what causes the flippage. Um, and it's not really the pain control or the activity restriction. So I guess, uh, Sean's saying we have to blame ourselves and not blame the patient, which is always a good rule, but I think things have changed and maybe the bars are more stable with different lengths of bars. So currently, how do you base your bar measurements, uh, the length of your bar? Do you base it based on the traditional posterior axillary line to posterior axillary line minus one centimeter? Do you base it on the mid-axillary line to mid-axillary line? Do you use the anterior axillary line? Uh, D, do you base it on the chest x-ray, uh, or do you base it on a CT scan? So, uh, this is the new polling question. And while that goes up, uh, let's, uh, get another opinion on what you do with this. Uh, Mac Harmon, Dr. Harmon, what, what do you, when you do these procedures, what do you, how long are your bars and what do you do for them? Uh, I have to be honest and say that I've sort of transitioned these operations to one of my partners. You're smart. You're very, very smart. So let's, let's go ahead. I don't do it that often anymore. Sorry. Well, let's, let's go ahead and see what else we have on our next, uh, the next slide. And let's look at this idea of shorter bars. Do we have a poll result? Is that coming up yet? Um, yeah, most people are saying mid-axillary line to mid-axillary line. And then the next most common is anterior, axillary line to anterior axillary line. So it looks like we are going maybe just shorter bars. So what's the, uh, what's the idea with shorter bars? Dr. Wagner, what do you got? I mean, what a, what a great transition from talking about bar flippage and technique. Uh, so this, uh, this slide's taken us all the way back to the early 2000s. This was a description by Pilegaard in Denmark, where they suggested to start using a shorter bar. Yeah, it's bent and placed asymmetrically so that the right side usually covers two rib spaces. The left side has a single stabilizer. It's usually placed right at the inflection of the bar just outside the chest wall. Lately, they say they don't place any fixating sutures on the right side at all. And they describe oblique bar placements, cross bars in some cases, and their large series, they found, uh, this results in well below 1% with flipped bars. And they started to even use more bars per patient. Um, yeah, that's a closeup of that, that image. Uh, if we can advance the slide. Thanks. Uh, I also want to bring up that some physics-minded surgeons did this really interesting computational model to show the sites of stress points with tradition U-shaped bars in contrast to shorter flat bars. The flatter bars focused the stress on the sternum, while the bigger curved bars had more of what they called parasitic forces that resulted in unwanted horizontal and torque action at the bar ends. So in their pilot clinical series, they didn't install stabilizers with the short flat bars and they still had pretty favorable preliminary results. We can advance the slide one more. And bringing this up because the future may involve creative ways to take the guesswork out of shaping a nice short bar in the operating room. This is Huang and colleagues. They used CT-based 3D modeling to print plastic templates that were sterilized and used in trial. They reported better corrections with fewer bars and shorter OR times. All you need is a good CT, 3D rendering software, a 3D printer, and some plastic that you can sterilize. Great. So we did the pull, we went over the pull results. Anyone else? Shorter bars or longer bars? Uh, Sean St. Peter. So we, um, measure just from where the middle of the incision is, which ends up being roughly mid-axillary, maybe a little bit more anterior than that. So not, not a full short bar, but it's, uh, it wraps around on both sides. And I was just looking, we did an updated series of 554 patients a couple of years ago, just before Whit left. And, um, our rotation rate was 0.7%. And what we don't have in that manuscript is, I think, across the board, it was within the first few years of experience when surgeons come on, um, because you get that one flip and then you typically don't have that happen again. Great. Great. All right. So it seems like we're moving towards shorter bars. It seems more stable. Um, physics wasn't my strong point, so I'll believe that slide. Um, I'm sure everyone else, uh, understood that one. So let's move on to the next, uh, topic here. Uh, so I'll advance the slide to our next, uh, polling question. And it is, are there any special maneuvers when passing the introducer behind the sternum? Um, uh, what do people do when passing the introducer behind the sternum? So as we, uh, come up with that polling question, um, uh, let me see, uh, Dr. Wolkin, what do you do with urinus procedures? Or do you, did you also pass that off to your junior faculty and not have to field all the phone calls like Dr. Hardman does? No, I, I try to, but occasionally I get pulled into those procedures. Um, you know, I, I now do a sternal elevator. So we, we use the sternal elevator at Akron Children's. Um, I initially, uh, resisted it. The other thing I do that nobody ever talks about is I go from the right, I go from the left chest to the right chest because the angle, because if you go from the right chest to the left chest, you're coming down and whatever you're passing across is pointing right at the ventricle. Um, I know you're hugging it and everything, but if you go from the left chest to the right chest, you actually are coming around and you miss and you know, you almost miss everything. You still have to be careful, but I wonder if, uh, I'm curious if anyone else on the panel does that. Let's, let's table that thought because that's our next question. You're, you're a reader. So let's go with this, uh, looks like the polling results. Most people do use a sternal elevator, but I I'm interested in the sub-xiphoid incision. I, I, I noticed in that flexible and that flex picture that Dr. St. Peter showed us, kid had an extra incision and what's the benefit of that? Dr. Sean, do you want to discuss the sub-xiphoid technique? I don't know if this- Dr. Yeah. Yeah. So Ron, Ron Sharp brought that to our group, um, because, you know, he was trained with Ashcraft and Holder in, in open heart surgery and in mobilizing to do a sternotomy. That's how you start. You make your incision just underneath the sternum and then you free up that whole space so that you can run your saw up there. And as a result, you create enough finger space that you're passing the bar and you're passing the, uh, the, the introducer onto your finger instead of passing it into an open space. So you reach in there, you feel it, you pop onto your finger and in, in that capacity, it kind of nullifies the right to left, left to right question because you're, um, because you're just feeling it the whole way through. And currently we go right to left, left to right, depending on which side you started with cryo. To Steve's point, we've been able to get that time back because while we're doing the cryo, we get the other side going, get the dissection done, get the, the umbilical tape passed through so that by the time the last cryo fires, you pull the tape and flip the bar. So that's the only thing that's left. And this is a technique that WIT edited. Um, and this is only a minute long, but that's the point is you can usually, you can go around the, the xiphoid or you can cut it out. And he was a fan of the retractor. I haven't really done that recently because you don't really need it, but there's the introducer and you're, you're just feeling it come through. And then we pass the umbilical tapes bar goes to the end of it. So do you still use the sub-xiphoid incision now that you've adopted cryo and have lower cost? Yeah. Yeah, we do. Um, it's, we had a 0% incidence of, of pericarditis, which has been as high as five to 10% in some series. And it, it means that we're not entering the pericardium really in any capacity. And so it's, I'm not saying it's necessary, obviously it's not because a lot of groups don't use it and have perfectly safe results, but it is awful comforting to be able to pass it with palpation. Hey Steve, if I could just, if I could just make a, an additional comment that, uh, Dr. Sharp came up with this idea before thoracoscopy was really described, much less used extensively. And by the time thoracoscopy became sort of mainstream, we'd probably done several hundred of these using the sub-xiphoid incision and everyone felt comfortable using it. So I think that the group in Kansas City has just continued to, um, to use that technique. And at least to my knowledge, we had not ever had, we've not ever had a cardiac injury. And so the idea of thoracoscopy or sternal elevator or vacuum bell in the operating room or sub-xiphoid incision, the idea is to, uh, not injure the heart. So whatever technique helps you do that, I think is the technique you want to use. Yeah. 100% agree that safety is first and, um, and that's where the sternal elevator seemed to really play a big role, uh, as far as, uh, increasing that space and making that bend when you go either right to left or left to right. It's hard to actually make the bend in the really, really deep, um, pectus excavatums with a really deep, uh, with a really high pectus index. So, uh, all very helpful techniques. So, uh, Steve, I would, I would just to add, I mean, we, I use a sternal elevator in about 10% of the cases. I think in the average kid that we do that's younger, you know, between the chest is pliable enough. You see well enough with thoracoscopy, you can get the right angles. You don't need to do it, but I, and so it's, it's not concern and we've never had a heart injury either. And I think you can see well enough if you work the scope the right way and you come in, I go right to left, but you come up under the sternum and you can flip the scope and look upside down. What you can't do when you have a really deep pectus and a really steep pectus, you can't enter the chest in and out at the right location and you get more intercostal tear. And I think the bars are less unstable. And so I do think in those really deep patients where there's not flexibility using a sternal elevator, as opposed to, you know, I don't disagree with the safety aspect and obviously you should do what you're safe with, but having the sternum elevated in those really deep stiff pectuses allows you to enter the chest basically in the mid clavicular line, come out under the sternum, get out on the other side of the mid clavicular line, which is what I try to aim for to have the most stable bar. We use a short bar and I think that we get, we get, do less tissue damage and have a better repair, but I don't think it's necessary in, in every case. And I think if you're, if you use thoracoscopy appropriately, you can, you know, avoid most of the kits we do, you can avoid the need for sternal elevation or a subtyphoid incision or anything else. But again, obviously you should do what you feel safe with. Hey, Steve. So how do you select the severe patient that you're going to use the sternal elevator on? Is it an eyeball test or are you looking at the CT scan and looking at the Haller index or how do you plan on having the sternal elevator in the OR? So, I mean, we always have it available, but you know, so it tends to be older males who are stiffer and are deeper. So, you know, if there's, if there's pectuses down and, you know, it's touching their spine or it's significantly deep, you know, so a Haller index well over, you know, three and a half, but obviously some of the index don't really correlate with what you see. So we sort of, we get the patient asleep, we look at them, definitely older males. So if they're over 16 and it's a significant defect and they're stiff, then we use it. But if it's a, you know, if it's a 13 year old male and it's moderate and I feel like there's enough pliability, then I feel like I can be in line with where I want to be and do it just with the bar itself. Then I'm pretty comfortable with it, but there have been one or two cases where I've gotten in, you know, I think I'm going to be fine passing the bar and realize I can't, you know, I just can't overcome the anatomy and the stiffness, in which case we'll just stop and put in the elevator. So, you know, it's a judgment call, but it's, you know, older patients and the more severe patients. Steve, we use the elevator in every case. You know, one of the most severe one is a power index of 44, in which case we needed to use two elevators to lift that chest wall up. But it offers, there's no guesswork. I mean, so, I mean, I think one of the things that Steve mentioned is being able to go in and out at the same inner space, I think is important. And so, yes, we use the elevator in every instance. Great. Great. I want to jump ahead, but also move backwards if that's such a thing. So, with the next slide, we talked about right to left, left to right, the age-old question. I'm interested to see what the current thoughts are when you pass the bar. I don't know. So, that's our next polling question. I don't know, Dr. Slater, if you have any thoughts on what you do and what you prefer or your group does. Sure. I've always done right to left. I never even thought about doing left to right, I must admit. So, I'm also learning something new and think that's a really fascinating idea. So, I'm very curious to hear your slides about this. I don't think we have any, well, I don't think we have any slides. We have lots of opinions, but we'll wait for the thoughts. It's interesting. I learned left to right and then I went back to right to left and found personally right to left being easy, but I'm also using a sternal elevator and thoracoscopy. So, I go the whole distance as far as ensuring safety and making sure we pass that. And then now my junior colleague has a peanut through a different incision, a laparoscopic peanut, and that has even made the dissection even much better. So, let's see what the polling, I don't know if the polling question's up yet. Do we have any results? Yeah, it's up. Right now it's about two-thirds are saying right to left, and then the other third is saying left to right. But it's updating as we speak. Great. What do you guys do? Well, I think even in our group there's, you know, there's probably certain preference. I actually always did it left to right and really for the same reasons that Mark has talked about. It was easier for me if I was on the patient's right side to put my left finger, index finger in the sub-siphoid space and then use my right hand to direct the bar, you know, from left to right and then the other way. But I think it's, I think it's surgeon preference and as long as you have the sub-siphoid space well dissected and everything's clear, then it probably doesn't make a whole lot of difference. I'm assuming that most people pass it right to left because they put the thoracoscope in the right chest. But at least for me using the sub-siphoid incision, I like to pass it left to right. So the reason I started going left to right was really because when, after Don Nuss gave the presentation, he showed it right to left and Keith Jorgensen, being Keith Jorgensen said, you know, I think it's better if we go from the left to the right, less chance of hitting the heart. And that's how we started doing it. We used thoracoscopy even early on, but I think probably most of Keith's disciples, myself included, I think we all do it left to right. Interesting. Interesting. Great. It's always great to hear. So it looks like, as mentioned earlier, about three-fourths go right to left and a fourth go left to right. So good reasons for both. I think we can jump ahead to one last polling question here. Some unique cases. This one actually came up to me and I don't know the right answer. We had a patient scheduled for a Nuss repair last week and the weekend before he came up with a spontaneous pneumothorax. Pneumothorax was treated non-operatively. We'll find out more about treatments of spontaneous pneumothorax, I think later in this course. But he was discharged and then, and then the dad asked me, what do we do? Do we proceed with the Nuss repair as soon as we can? Do we delay it for a certain time? Do I need to do a blebectomy with the Nuss during, then the Nuss repair? Do I do a blebectomy at the time of the Nuss repair? Do I do, go the whole distance and do a Nuss, a blebectomy, and a pluridesis? What would everyone do? This is a, something that's still stopping me and this patient's waiting for your answer here. So we need to know, we need to hear from you. Dr. Lee, what did you do at that, when you say a pneumothorax is treated conservatively? Well, not to ruin everything, but we, we, we watched the patient for four hours in the ER, was shot with a chest x-ray and then was discharged. I would argue that the conservative management is putting a chest tube in. Oh, okay. So the, we, we will hear more about that from an esteemed faculty who is trained at an incredible, by an incredible mentor. So that's coming up. So what do the poll results say? I'm interested. The patients are saying. Yes. A third are saying delay, well, actually it's changing. We're about a quarter each of delay, the Nuss repair, blebectomy, then the Nuss repair, blebectomy at the time of Nuss repair, or Nuss, blebectomy, and pluridesis at the same time. Right. Who wants to tackle this? This is an interesting topic from our faculty. Dr. Hartman doesn't do it. I won't pick on him. Who hasn't spoken yet? I think, I think it has to do with when you do how you manage pleuridesis. I mean, how you manage pneumothorax. If you do just a blebectomy, you're not hurting yourself for a subsequent procedure. If you're going to do an aggressive pleuridesis, then it's going to be tough to go back in again. So for me, I just do a blebectomy. I think the safest course of action is to deal with that, make sure you've done your best to mitigate the chances of it recurring, and then go back another time for for the Nuss procedure. Dr. Von Allman, you agree? You're his boss? Yeah. One of his bosses? Yeah. He's his bosses. Dr. Von Allman, you know, I, so first I'll give the disclaimer that I actually transitioned pectus repairs to my senior faculty, and that's why Dr. Garcia is on here. But, but it seems to me that you could do this in one procedure, and Vic has significant experience with doing, you know, sort of non-standard indications or doing pectus repairs in kids who have underlying issues or other problems at the same time. But I, I personally, it seems like you could do the, do a bleb resection as Todd described, but do it at the same time as you do the Nuss repair. Dr. Arka, what do you think? I mean, I would be concerned about, I guess it's a bleb, but technically it's now a clean contaminated case with an infant. I agree. What do you think, Dr. Arka? Huh? I'm muted. Well, here's the thing. If you weren't doing the Nuss procedure, would you do anything with the bleb? I probably would just do the Nuss procedure. In this, in this instance though, the patient is asymptomatic and has, has gone home. Is that not correct? Correct. The patient presented with pain and went home and then went to the ER, then had a pneumothorax diagnosed on the ER. And at that point it was recommended since just to watch the patient was stable over the course of four to six hours, and then eventually discharged home with some, with some pain control. But in follow-up is asymptomatic. And I think they're coming back to my clinic here. It's so early this afternoon and why I was forced today. And now I'm going to say, a fourth in the world is, is, is, is completely uncertain. So I'm not sure what to tell this patient. How about to seal Dr. Lee? I guess you'd have to take a look, correct? I mean, you can't not look. And then you have to take a look, um, at the time that you actually enter the space between the visceral, visceral and parietal pleura. If, if it looks as if, um, you have air emanating from the bleb, then you are compelled to do something at that point. And whether it's a, you know, um, and typically if it, if it's, it's big enough that you're looking at, you know, bubbles coming out of the area, then you'd probably need to, um, to secure that, that space. Um, so I think, um, I'd have to see what your operative findings are. I think if it looks good, I may just put a little tissue sealant there. Of course, I can't, uh, I would imagine I don't have any, um, randomized, uh, controlled trials, uh, on, um, pneumothorax and VATS, uh, at this point, but I, that's probably what I would do. Great. Well, any last comments or questions? I, I do want to thank you. That was sneaky, by the way, that you're seeing that patient disaster. Had I known I would have looked at my, my clinic stuff for next week. I want to thank you all for participating. I think we're back on time, Todd. I don't know if you, uh, want to take it from here for our next session. Um, Yeah, that's, that's perfect for lunch. No, that's awesome. Um, we, we, I, I see Shin's here, um, but I think for the sake of time, um, um, Shin, I don't know if, if you wanted to make any final comments. Um, you know, I, I was actually asked to give the magnet update and I would just tell the group quickly that, you know, to remind us that, that we did a 15 patient trial looking at magnetic repair of pectus exocobotum and learned a lot of stuff about kids and braces and dealing with the FDA. And, you know, there was a steep learning curve for all the investigators in the, in the trial. And the, the bottom line is what we learned was it was safe to stick magnets in kids' chests. It was pretty well tolerated. The surprising number of kids wore the brace for a surprisingly long amount of time. And the results weren't as effective as we had thought or had hoped. It looks like it's probably most effective in young kids. Um, and we haven't lost our enthusiasm, but I'll tell you that, the advent of cryoablation, which I have to give credit to Gary Raff for, for really pushing this. He's one of our cardiac surgeons that does NUSTAs over here with us for, for pioneering this. Um, has really made it so that the, the need for a less invasive or less painful operation has really maybe sort of evaporated. Um, that said, I think for the youngest of kids with super flexible chest, the magnet may be, um, a decent option. And, you know, we continue to look at, um, other options for that. In fact, um, Mike Harrison, uh, has just sort of reinvented or sort of reinvigorated our interest in magnets for that. I, and, and that was a good, I mean, that was perfect. That was, uh, you know, exactly the purpose of this course, a little update there. Um, and I, I hopefully we'll be hearing from you more and more to see how this progresses. Um, thanks for coming on and Steve, thanks for keeping us exactly on time. You got us back on track. Thank you for doing that. Very well, Ron. That was, uh, a ton of stuff learned in a very short amount of time on pectus. I will tell you that, um, in planning this, a lot of us decided that this probably deserves its own, um, own longer session. So we're planning to have a pectus event in the fall. If there's anything that's discussed today that everyone feels we should do, you know, more, a more thorough event on, if people want that, let us know and we can, we can have one of those.
