Update Course Rewind: Pectus Excavatum 2021

Dr. St. Peter's hospital completed a randomized trial of 110 patients comparing epidural and PCA, and epidurals did not show superior results

After implementing cryoanalgesia, the first patient went home on post-operative day one, leading Dr. St. Peter to discontinue enrollment in the epidural/PCA comparison trial

Cryoanalgesia uses cold temperatures to cause a conduction block that interrupts pain impulses to the brain

The cryoanalgesia technique involves freezing ribs 4 through 7 for two minutes per rib

Cryoanalgesia should not be performed on rib 8 or below because it can cause abdominal wall paralysis

With cryoanalgesia, length of stay decreased from four days (baseline) to one day

Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain control methods

Dr. Garcia expressed concern that there are no long-term studies of cryoanalgesia and potential for chronic neuropathic pain

Medical devices and implants are not required to undergo clinical trials before introduction to market, unlike medications which require FDA clinical trials with long-term results

Dr. Garcia's hospital uses erector spinae catheters placed by the pain team with ultrasound guidance, positioned juxtaposed to but not in the vertebral space

With erector spinae catheters, hospital stay is two days, catheters remain in place for five days total (three days at home on automated pump), and families remove catheters at home on day five

Erector spinae catheters reduced opioid requirements both in hospital and outside the hospital, achieving two-day length of stay compared to four or five days with epidurals

Dr. Rothenberg initially had concerns about cryoanalgesia including added operative time and risk of neuralgia, but after four cases observed that patients not only went home earlier but felt significantly better at discharge

Multimodal pain control components include Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for post-anesthetic nausea, ketamine to avoid opioids, and support from child life specialists, mindfulness resources, and physical therapists

Dr. Ponsky's multimodal regimen includes preoperative counseling, gabapentin pre and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics

At Nebraska where Dr. Rayner practices, length of stay is under two days and patients are off opioids by one week using multimodal pain control

Bar flippage typically occurs early and is caused by the bar sitting in an incorrect intercostal space, poor positioning, inadequate wrapping, or insufficient securing

Bar flippage is a surgical technique issue; the bar must sit in a comfortable position before securing or it will not remain stable

Computational modeling by physics-minded surgeons showed that shorter flat bars create more pressure on the sternum compared to traditional U-shaped bars, potentially increasing stability

Bar length selection is not standardized, though there is a trend toward shorter bars based on computational stress modeling

Dr. Wolkine uses sternal elevator in about 10% of cases, primarily in younger patients where thoracoscopy provides adequate visualization

Sternal elevation in deep, stiff pectus cases allows less tissue damage and better repair

Dr. St. Peter uses sternal elevator in every case because it eliminates guesswork and facilitates entering and exiting at the same intercostal space

Techniques to avoid cardiac injury during introducer passage include thoracoscopy, sternal elevator, vacuum bell in the operating room, and sub-xiphoid incision

Some surgeons pass the bar from left chest to right chest because passing right to left directs the introducer toward the ventricle

Bar passage direction (left-to-right versus right-to-left) is surgeon preference; as long as the sub-sternal space is well dissected and visualization is clear, direction likely does not make a significant difference