Update Course Rewind: Pectus Excavatum 2021
With Dr. Sean Saint Peter & Dr. Victor Garcia & Dr. Steven Rothenberg & Dr. Justin Wagner · hosted by Dr. Cecilia Gigena · StayCurrentMD
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Dr. Saint Peter's institution completed a randomized trial of 110 patients comparing epidural to PCA for pectus excavatum pain control, and epidurals did not show superior performance.
In Dr. Saint Peter's cryoanalgesia trial with approximately 30 patients per group, equipoise was lost when patients went home on post-op day one.
The cryoanalgesia technique involves counting down to the 4th rib and freezing underneath it for 2 minutes per rib, treating ribs 4 through 7.
Cryoanalgesia should not be performed on rib 8 or below because it can cause abdominal wall paralysis.
With cryoanalgesia, hospital length of stay decreased from 4 days to 1 day at Dr. Saint Peter's institution.
Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain management approaches.
Dr. Garcia's concern about cryoanalgesia is the absence of long-term studies and unknown potential for future adverse effects such as chronic neuropathic pain.
Unlike drugs, medical devices and implants are not required to undergo clinical trials before being introduced to the market by the FDA.
Dr. Garcia's institution studied approximately 100 patients comparing epidurals to erector spinal catheters for pectus excavatum pain management.
Erector spinal catheters are placed by the pain team with ultrasound guidance and are positioned juxtaposed to but not in the vertebral space.
With erector spinal catheters, the catheters stay in for 5 days, hospital stay is 2 days, and on the 3rd day while patients are at home, the catheters are pulled out by the family.
Dr. Garcia's institution achieved 2-day hospital stays with erector spinal catheters and reduced opioid requirements both in-hospital and at home.
Erector spinal catheters achieve shorter stays than the 4-5 days seen with epidurals, though not the one-day stays achieved with cryoanalgesia.
Dr. Rothenberg's initial concerns about cryoanalgesia were the added operative time and concerns about neuralgia and complications.
After approximately 4 cases, Dr. Rothenberg observed that cryoanalgesia changed not just when patients go home but how they feel when they go home, describing the results as unbelievable.
Dr. Rothenberg agrees with Dr. Garcia's concerns and supports the need for a registry to track long-term cryoanalgesia outcomes.
Multimodal pain control options include Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for post-anesthetic nausea, and ketamine to avoid opioids.
Non-pharmacologic multimodal approaches include child life specialists, mindfulness resources, and supportive physical therapists.
Bar flippage typically occurs early and is caused by the bar sitting in a funky interspace, sitting in a bad spot, not being wrapped tight enough, or not being secured well.
The bar must sit in a comfortable position before securing or it will not stay in place; securing alone does not prevent bar flippage.
Dr. Rothenberg believes bar flippage is completely a surgical issue, not related to pain management technique.
Dr. Rothenberg uses a sternal elevator in about 10% of cases, primarily in really deep stiff pectuses where it allows less tissue damage and a better repair.
In average younger patients, thoracoscopy provides adequate visualization without needing a sternal elevator.
Dr. Garcia uses the sternal elevator in every case because it eliminates guesswork and allows entry and exit at the same interspace.
Dr. Saint Peter continues to use subxiphoid incision along with thoracoscopy, sternal elevator, or vacuum bell in the operating room as safety techniques to avoid cardiac injury.
One surgeon passes the bar from left chest to right chest because passing right to left directs the instrument toward the ventricle.
One surgeon learned left to right but switched to right to left and found it easier, particularly when using external elevator and thoracoscopy for safety.
Direction of bar passage is likely surgeon preference and does not make much difference as long as the substernal space is well dissected and everything is clear.
Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain.
For medications, the FDA requires clinical trials with long-term clinical results before approval, but this is not required for medical devices and techniques like cryoanalgesia.
Dr. Ponsky's best multimodal treatments are preoperative counseling, gabapentin both pre and postoperatively, methadone, clonidine, bowel regimen medications, and anti-emetics.
At the institution where Dr. Wagner trained in Nebraska, Steve Rayner achieves length of stay under 2 days with patients off opioids by 1 week.
Physics-minded surgeons created a computational model showing that shorter flat bars have more pressure on the sternum compared to traditionally U-shaped bars, making them more stable.
Dr. Wolon uses a sternal elevator for pectus excavatum repair at Akron Children's Hospital.
Dr. Holcomb's principle is that whatever technique helps avoid injuring the heart is the technique that should be used.
Dr. Slater has always performed the Nuss procedure right to left and had not previously considered left to right.