Update Course Rewind: Pectus Excavatum 2021

In a randomized trial of 110 pectus patients comparing epidural to PCA, epidurals did not provide superior pain control.

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

The cryoanalgesia technique involves two minutes of freezing per rib, applied to ribs four through seven; ribs eight and below should not be treated due to risk of abdominal wall paralysis.

After implementing cryoanalgesia, median length of stay decreased from four days to one day.

Cryoanalgesia dramatically reduced median morphine equivalents compared to epidural/PCA approaches.

There are no long-term studies of cryoanalgesia outcomes, raising concerns about potential future adverse effects such as chronic neuropathic pain.

Erector spinae catheters are placed by the pain team with ultrasound guidance in a position juxtaposed to but not within the vertebral space.

With erector spinae catheters, hospital stay is two days, catheters remain in place for five days on an automated pump, and families remove the catheters at home on the third day.

Erector spinae catheters reduced hospital stay compared to epidurals and decreased opioid requirements both in-hospital and post-discharge, though not achieving one-day discharge.

Cryoanalgesia changed not just discharge timing but how patients feel at discharge, with a qualitatively different recovery experience.

Multimodal pain therapy components include Tylenol, NSAIDs, precedex for gentle wake-up, dexamethasone for post-anesthetic nausea, ketamine when used by experienced practitioners, and support from child life specialists and physical therapists.

Optimal multimodal therapy includes preoperative counseling, gabapentin pre- and postoperatively, methadone, clonidine, bowel regimen medications, and antiemetics.

With optimized multimodal pain control, one center achieved length of stay under two days with patients off opioids by one week.

Bar flippage typically occurs early and results from the bar sitting in an incorrect intercostal space, poor positioning, inadequate wrapping, or insufficient securing; proper initial bar positioning is more important than securing technique.

Computational modeling demonstrates that shorter flat bars create more pressure on the sternum and are therefore more stable than traditional U-shaped bars.

Sternal elevator use varies by case complexity; one center uses it in approximately 10% of cases (younger patients with adequate thoracoscopic visualization), while it is particularly valuable in deep, stiff pectus cases to reduce tissue damage.

Some centers use sternal elevator in every pectus case to eliminate guesswork and ensure consistent entry and exit at the same intercostal space.

The primary goal of techniques including thoracoscopy, sternal elevator, vacuum bell, or sub-xiphoid incision is to prevent cardiac injury; surgeons should use whichever technique best achieves this safety goal.

Passing the introducer from left chest to right chest is preferred by some surgeons because right-to-left passage directs the instrument toward the ventricle during the crossing maneuver.

Introducer passage direction (left-to-right versus right-to-left) is likely surgeon preference and does not make significant difference when the substernal space is well dissected and visualization is clear.